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LIST   OF   PLATES   IN   VOL.  II 

Plate  81  (Colour)     ......  Frontispiece 

Carcinoma  of  the  breast  of  atrophic  type,  showing  early  "  cancer 
en  cuirasse." 

FA' 

Plate  82  (Colour) 10 

Paget's  diseases  of  the  nipple. 

Plate  83  (Colour) 52 

Naked-eye    section  of    a    fibroid   cancer   of    the  breast  removed 
by  operation. 

Plate  84  (Colour) 52 

A  similar  section    to    that    shown  in  Plate  83,  from  a  soft  or 
medullary  cancer  of  the  breast. 

Plate  85  (Colour) 118 

Large  hydatid  cyst  of  the  spleen. 

Plate  86  (Colour) 164 

The  lymphatic  glands  draining  the  tongue. 

Plate  87  (Colour)     .  .  .  ' 200 

Lymphangioma  of  dorsum  of  the  tongue. 

Plate  88 218 

Fig.   1. — Section    of    tongue    showing  cancerous  growth  invading 

the  genio-hyo-glossus. 
Fig.  2. — Section   of   tongue  showing   cancerous  growth  invading 

the  hyo-glossus. 

Plate  89 272 

Toy  bicycle  impacted  in  the  oesophagus. 

Plate  90 392 

Carcinoma  of  second  part  of  the  duodenum. 

Plate  91 402     t 

Gastro-duodenal  fistula,  the  result  of  carcinoma  of  the  stomach. 

Plate  92 440 

Complete  longitudinal    section    of    diverticulum    with    accessory 
pancreas. 

Plate  93  (Colour) 482 

Strangulation  of  a  loop  of  small  intestine. 

Plate  94  (Colour) 402 

Chronic  primary  intussusception  in  an  old  man. 

xi 


xii  LIST   OF    PLATES   IN   VOL.   II 

FACING    PAG 

Plate  95  (Colour)     ........      51< 

Tuberculosis  of  intestine,  leading  to  multiple  strictures. 

Plate  96  (Colour) 51' 

Ileo-ctecal  tuberculosis. 

Plate  97  (Colour) 54i 

A. — Appendix  distended  by  a  large  concretion. 

B. — Acutely  inflamed  appendix. 

C. — Perforated  appendix,  with  concretion. 

D. — Gangrenous  appendix,  with  concretion. 

Plate  98 56: 

Fig.  1. — Section  of  intestine  from  a  case  of  peritonitis  of  sixteen 
hours'  duration,  showing  inflammatory  deposit  which 
becomes  less  as  the  mucous  coat  is  approached. 
Fig.  2. — Section  of  diaphragm,  showing  organization  of  fibrinous 
deposit  in  a  case  of  chronic  septic  peritonitis. 

Plate  99 74 

Varieties  of  gall-stones. 

Plate  100  (Colour) 75 

Acute    cholecystitis,  the  result   of   calculous    obstruction   of   the 
cystic  duct. 

Plate  101,  with  key  facing  (Colour)  .  .  .  .76 

Sloughing   of  the  pancreas,  the   result  of   acute  inflammation  of 
seven  weeks'  duration. 

Plate  102 77 

Enormous  distension  of  the  gall-bladder,  secondary  to  malignant 
disease  of  the  head  of  the  pancreas. 

Plate  103  (Colour) 82: 

Tuberculous  disease  of  the  kidney. 

Plate  104  (Colour) 83: 

Multiple  calculi  of  the  kidney. 

Plate  105  (Colour) 94< 

Fig.  1. — Tertiary  syphilis  (gumma)  of  the  testis  with  a  localized 

hydrocele. 
Fig.  2. — Teratoid  tumour  of  the  testis  (fibro-cystic  disease). 

Plate  106  (Colour) 941 

Rapidly  growing  malignant  tumour  of  the  testis,  with  secondary 
nodules  in  the  spermatic  cord. 


A  SYSTEM  OF  SURGERY 


THE     BREAST 

By  W.  SAMPSON   HANDLEY,  M.S.Lond., 
F.R.C.S.Eng. 

ANATOMY  OF  THE  BREAST 

The  mamma  is  an  organ  developmentally  arising  from  the  skin, 
intercalated  in  the  thickness  of  the  subcutaneous  fat,  and  probably 
representing  a  highly  developed  group  of  sebaceous  follicles.  It  is 
firmly  attached  to  the  skin  at  the  nipple,  and  is  connected  to  it 
at  numerous  other  points  by  fibrous  septa  called  the  suspensory 
ligaments  of  Astley  Cooper.  The  size  of  the  breast  is  no  index  to 
its  secreting  power,  since  prominent  mammae  often  consist  mainly 
of  fat, 

Each  mamma  consists  of  from  twelve  to  twenty  lobes,  which  are^ 
really  separate  sector-shaped  glands,  packed  closely  together  in  one 
plane,  their  ducts  converging  upon  the  nipple,  and  opening  byseparatc^ 
orifices  upon  its  summit.  The  autonomy  of  each  lobe  is  an  important 
fact,  since  disease  ot  one"  or  more  of  the  lobes  is  thereby  hindered 
from  spreading  to  the  adjoining  ones.  In  some  cases  of  disease  a 
sector-shaped  tumour  may  be  observed  mapping  out  the  limits  of  the 
affected  lobe  or  lobes.  It  is  possible  sometimes  to  excise  the  diseased 
lobes  of  the  breast  without  interfering  with  the  healthy  ones.  The 
main  duct  of  each  lobe,  before  opening  upon  the  nipple,  is  dilated  to 
form  a  small  reservoir  or  ampulla,  £  to  £  in.  in  diameter,  the  undue 
distension  of  which  may  give  rise  to  galactocele,  or,  if  lactation  is 
not  in  progress,  to  a  retention  cyst  containing  serous  fluid.  Each 
lobe  of  the  breast  is  composed  of  a  number  of  lobules  which  bear  to 
the  main  duct  of  the  lobe  the  relation  of  a  bunch  of  grapes  to  its  stalk. 
A  lobule  of  the  breast  consists  of  a  small  rounded  packet  of  fibrous 
b 


2  THE   BREAST 

tissue,  enclosing  a  small  milk-duct  surrounded  by  a  group  of  acini 
or  alveoli,  the  blind  glandular  recesses  which  discharge  their  secretions 
into  the  duct.  A  large  amount  of  fibro-fatty  tissue  intervenes  between 
the  lobules,  and  serves  to  cushion  and  protect  them.  In  microscopic 
sections  the  ducts  are  distinguished  by  their  single  lining  of  columnar 
epithelium,  while  the  alveolar  or  secreting  cpitlir-lium  is  cubical.  The 
epithelium  of  the  alveoli  and  ducts  rests  upon  a  basement  membrane 
of  flattened  endothelial  cells.  In  microscopic  sections,  breast  tissue 
can  be  recognized  by  these  characteristic  groups  of  cubical-celled 
alveoli  containing  one  or  more  columnar-celled  ducts.  The  inter- 
vening fibrous  and  fatty  tissue  contains  here  and  there  the  section 
of  a  larger  duct,  the  whole  presenting  a  characteristic  histological 
picture. 

Limits  of  the  mamma. — Stiles  showed  that  the  outlying 
lobules  of  the  breast  extend  as  a  thin  marginal  fringe  in  the  subcu- 
taneous fat  considerably  beyond  the  limits  of  the  mammary  promi- 
nence. Including  these  outlying  portions,  the  vertical  diameter  of 
the  breast  extends  from  the  lower  border  of  the  second  rib  to  the 
sixth  costal  cartilage  at  the  angle  where  it  begins  to  sweep  upwards 
to  the  sternum.  Its  horizontal  diameter  extends  from  a  little  within 
the  edge  of  the  sternum,  opposite  the  fourth  rib,  to  the  fifth  rib  in 
the  mid-axillary  line.  The  lower  and  inner  margin  of  the  breast  over- 
lies the  sixth  costal  cartilage  midway  between  the  angle  and  its  sternal 
end,  and  is  situated  only  about  an  inch  from  the  dangerous  area  in 
breast  cancer — the  area  of  epigastric  invasion. 

In  a  majority  of  cases  a  tongue-shaped  projection  of  breast  tissue, 
known  as  the  axillary  tail,  extends  to  the  base  of  the  axilla,  under 
cover  of  the  lower  edge  of  the  great  pectoral.  Frequently  the  axillary 
tail  lies  in  almost  direct  contact  with  the  lowest  of  the  axillary 
lymphatic  glands. 

Relations  to  the  underlying  muscles.— Roughly  speak- 
ing, the  upper  and  inner  two-thirds  of  the  breast  rests  on  the  great 
pectoral  muscle.  The  lower  and  outer  third  of  the  breast  lies 
mainly  on  the  serratus  magnus — a  fact  oftenun wisely  ignoredin 
the  operation  for"  cancer!  At  its  periphery  the  breast  rests  to  a  small 
extent  below  upon  the  aponeurosis  of  the  external  oblique  and  the 
origin  of  the  rectus,  externally  upon  some  of  the  digitations  of  the 
external  oblique.  A  portion  of  the  breast,  and  especially  its  axillary 
tail,  rests  against  the  lower  part  of  the  inner  wall  of  the  axilla,  and 
is  separated  from  the  axillary  glands  only  by  a  fatty  and  ill-defined 
portion  of  the  axillary  fascia.  The  muscular  relations  of  the  breast 
are  of  great  importance  in  the  operation  for  breast  cancer,  for  every 
muscle  which  directly  touches  the  affected  organ  is  very  likely  to 
be  infected  by  microscopic  secondary  growths  quite  early  in  the  case. 


MAMMARY    LYMPHATICS 

Moreover,  the  thinner  the  muscular  layer  which  separates  the  primary 
growth  from  the  pleural  oavity,  the  greater  the  probability  "f  early 
pleura]  invasion.  'Thus,  in  outlying  mammary  growths  the  prognosis 
is  worse  than  in  the  case  of  growtTTs  whicTl  are  separated  from  the 
innh  r1yuig_ribs  b*y~thc  thickness  ot  the  great  pcetoraTnvusrli-.  Portions 
of  the  glandular  tissue  of  the  breast  are  sometimes  found  beneath 
the  pectoral  fascia,  in  the  substance  of  the  greal  pectoral  muscle. 

Blood  supply.  The  arteries  which  Bupply  the  mammary 
gland  arc  branches  of  the  internal  mammary,  Long  thoracic,  superior 
thoracic,  and  perforating  brandies  from  the  second,  third,  and  fourth 
intercostal  arteries.  It  has  been  recently  shown  thai  the  important 
perforating  branches  of  the  internal  mammary  artery  for  the  most 
part  turn  round  the  margin  of  the  breast  and  spread  out  upon  ita 
superficial  aspect  before,  penetrating  its  substance.  Thus,  the  breasl 
may  be  extensively  stripped  up  from  the  pectoral  muscle  without 
interfering  with  its  blood  supply — a  fact  of  surgical  importance 
(see  p.  40). 

Lymphatic  vessels. — The  breast  is  richly  supplied  with 
Lymphatic  vessels.  Each  lobule  possesses  its  own  system  of  minute 
lymphatic  capillaries  which  come  into  close  relation  with  the  acini. 
Many  of  the  lymphatic  vessels  of  the  breast  pass  into,  or  communicate 
with,  the  pectoral  lymphatic  plexus,  which  lies  in  the  pectoral  fascia 
in  immediate  contact  with  the  posterior  surface  of  the  mamma.  On 
the  anterior  surface  of  the  breast  a  plexus  of  large  lymphatic  vessels 
is  present  beneath  the  skin  of  the  areola  (subareolar  plexus  of  Sappey). 
There  can  be  no  doubt  that  the  normal  lymph  drainage  of  the  breast 
flows  almost  exclusively  to  the  axillary  glands  of  the  same  side-.  Large 
lymphatic  trunks  connect  the  pectoral  lymphatic  plexus  and  the 
subareolar  plexus  with  the  lower  glands  upon  the  internal  wall  of 
the  axilla.  It  is,  however,  a  mistake  to  regard  the  pectoral  lymphatic 
plexus  as  an  anatomical  entity.  It  is  in  reality  merely  a  conventional 
subdivision  of  the  deep  fascial  lymphatic  plexus  (Fig.  251),  whose  net- 
work of  intercommunicating  channels  forms  a  single  system  investing 
the  entire  body.  The  unity  of  this  plexus  is  a  fact  of  capital  importance 
in  the  pathology  of  breast  cancer,  for  it  allows  the  indefinite  spread 
of  the  process  of  permeation  (see  p.  60).  This  great  plexus  is  divisible 
by  the  median  plane  of  the  body  and  by  two  horizontal  planes,  passing 
through  the  umbilicus  and  the  clavicles  respectively,  into  six  "  catch- 
ment areas,"  three  on  each  side,  which  drain  respectively  into  the 
cervical,  the  axillary,  and  the  inguinal  glands.  Within  each  area  a 
special  set  of  trunk  lymphatics  arises  from  the  plexus  and  converges 
on  the  corresponding  set  of  glands.  These  trunk  vessels  are  of  such 
a  size  that  fine  particles,  such  as  cancer  cells,  may  be  swept  along 
them  by  the  current,  to  lodge  in  the  corresponding  glands.     But  in 


THK   BREAST 


the  boundary  zones  of  the  catchment  areas  no  trunk  lymphatics  are 
present.  Here  are  found  only  narrow,  tortuous  channels,  not  navigable 
by  floating  cancer  cells,  and  only  to  be  penetrated  by  the  slower 
process  of  permeation. 

One  lymphatic  trunk  deserves  especial  mention.  It  arises  on  the 
posterior  aspect  of  the  breast  and  pierces  the  great  pectoral  muscle 
to   terminate   in   the   subclavian   lymphatic    glands,    without   passing 

first  into  the  lower 
lymphatic  glands 
of  the  axilla.  Con- 
sequently, in  breast 
cancer  the  sub- 
clavian glands  may 
be  found  enlarged 
before  the  lower 
axillary  glands 
have  become 
affected. 

The  subclavian 
glands  themselves 
are  of  great  sur- 
gical  importance. 
They  are  situated 
just  below  the 
clavicle,  internally 
to  the  first  part 
of  the  axillary  ar- 
tery and  vein,  and 
shielded  in  front 
by  the  great  pec- 
toral muscle  and 
by  the  costo-cora- 
coid  membrane. 
Owing  to  their 
sheltered  position  they  are  very  likely  to  escape  removal  at  the  hands 
of  an  inexpert  operator  for  breast  cancer.  Their  efferent  vessels  form 
the  afferents  of  the  supraclavicular  glands,  which  are  the  next  set  to 
be  involved  in  breast  cancer. 

It  has  been  sometimes  stated  that  efferent  lymphatic  vessels  from 
the  breast  pass  to  the  retrosternal  chain  of  glands  which  accompanies 
the  internal  mammary  artery.  It  is  doubtless  true  that  there  is  a 
mediate  communication  between  the  breast  and  these  glands  by  way  of 
the  pectoral  lymphatic  plexus  and  of  the  perforating  branches  which 
run  from  that  plexus  to  tho  glands  in  question.      But,  fortunately, 


Fig.  251. — The  trunks  of  the  fascial  plexus.  The 
fine  meshwork  of  vessels  constituting  the 
plexus  itself  is  only  partially  indicated  in 
this  figure. 

(After  Sappey's  "  Vaisseaux  I.y»iphati</ites.") 


MAMMARY    LYMPHATICS 

these  perforating  branches  musl  be  regarded  aol  as  true  afferenl 
lymphatics  bu1  as  men'  anastomotic  channels  "{  small  diamet 
and  sluggish  Btream,  along  which  embolic  transporl  oi  cancel  cells 
cannot  occur,  though  in  a  late  stage  of  the  disease  they  may  be  in- 
vaded by  permeation.  For,  while  invasion  of  the  axillary  glands 
is  an  early  and  almosi  constanl  event,  cancel  of  the  anterior 
mediastinal  elands  is  only  found   in   6#5  per  cent,  of  necropsies  for 

Jl    cancer. 
Lymphatic   communication   between   the  breasts. — 

It  will  be  clear  from  the  preceding  description  that   the  lymphatic 

systems  of  the  two  breasts  communicate  across  the  middle  line 
indirectly,  through  the  medium  of  the  fine,  vessels  of  the  fascial 
plexus.  Cancer  can  thus  only  spread  to  the  opposite  breasl  in  a 
late  stage  and  after  permeation  has  crossed  the  middle  line,  an 
event  which  is  usually  signalized  by  embolic  invasion  and  enlarge- 
ment of  the  opposite  axillary  glands.  For  sufficiently  obvious  reasons  \ 
this  embolic  glandular  enlargement  precedes  cancerous  deposit  in  the 
opposite  breast. 

Lymphatic  arrangements  of  the  skin.— It  was  formerly 
thought  that  breast  cancer  spread  in  the  plane  of  the  skin  along  a 
hypothetical  plexus  described  by  Arnold,  situated  at  the  junc- 
tion of  the  eorium  and  subcutaneous  tissue,  and  called  the  deep 
cutaneous  plexus.  Accordingly,  the  removal  of  a  very  large  area  of 
skin  was  considered  imperative.  In  point  of  fact  there  is  only  one 
cutaneous  lymphatic  plexus,  the  subpapillary  lymphatic  plexus,  and 
there  is  no  evidence  that  permeation  can  spread  to  any  extent  along 
this  plexus.  The  subpapillary  plexus  is  drained  by  small  vessels 
which  run  vertically  downwards  along  the  fibrous  septa  of  the  sub- 
cutaneous tissue  to  join  the  fascial  plexus.  Up-stream  permeation 
of  these  small  vessels  accounts  for  the  nodular  invasion  of  the  skin 
so  often  seen  in  the  later  stage  of  breast  cancer. 

From  the  muscles  small  tributaries  reach  the  fascial  plexus  on 
its  deep  aspect.  Up-stream  permeation  of  these  tributaries  is  respon- 
sible for  the  muscular  nodules  which  may  occur  in  a  late  stage  of 
cancer  in  the  pectorals,  the  serratus  magnus,  the  deltoid,  the  rectus 
abdominis,  the  intercostals,  or  other  muscles  which  lie  within  the 
area  of  permeation. 

Development. — The  breasts  remain  small  and  unimportant 
until  puberty.  Up  to  this  age,  and  permanently  in  the  male  breast, 
the  characteristic  alveoli  are  absent,  and  the  minute  milk-ducts  ter- 
minate in  blind  "  end-sacs,"  lined  by  an  epithelium  which  approxi- 
mates in  character  to  the  columnar  epithelium  of  the  ducts.  At 
puberty  the  alveoli  are  formed  as  hollow  buds  which  grow  outwards 
from  the  end-sacs  into  the  surrounding  tissues. 


6  THK   BREAST 

At  two  periods  of  life,  normal  activities  of  the  mammary  gland 
have  been  dignified  by  the  name  of  mastitis. 

1.  During  the  first  few  days  of  life  in  either  sex  the  breasts  may 
become  swollen,  and  a  few  drops  of  serous  fluid  or  of  true  milk  may 
be  discharged  from  the  nipple  (mastitis  neonatorum).  This  mastitis  of 
new-born  children,  like  the  jaundice  and  the  cutaneous  hypereemia 
which  accompany  it,  is  probably  due  to  the  first  onslaught  of  bacteria 
upon  the  aseptic  babe,  the  bacteria  of  the  skin  penetrating  some 
distance  along  the  ducts  of  the  breast.  It  has  no  clinical  importance 
and  should  be  let  alone  ;  unwise  and  active  treatment,  such  as 
massage,  may  prolong  and  aggravate  the  condition.  A  few  rare  cases 
are  on  record  where  infantile  lactation  has  persisted  for  several  weeks, 
and  in  one  case  for  over  three  months. 

2.  With  the  onset  of  puberty,  both  in  boys  and  in  girls,  the 
undeveloped  breasts  may  become  tender  and  swollen  for  some  days 
or  weeks  (mastitis  adolescentium).  At  the  same  time  a  scanty  serous 
discharge  exudes  from  the  nipple,  and  the  axillary  glands  become 
unduly  palpable.  No  treatment  is  required  for  this  condition,  which 
derives  its  only  importance  from  the  parental  anxiety  it  is  apt  to 
cause. 

At  pxiberty  in  the  female,  owing  to  the  rapid  development  of 
the  acini,  and  the  deposition  of  fat  between  the  growing  lobes,  the 
breast  begins  to  assume  its  characteristic  form  and  size.  The  onset 
of  pregnancy  leads  to  further  marked  changes  in  the  gland,  for  the 
details  of  which  a  work  on  obstetrics  should  be  consulted.  Many 
new  alveoli  are  formed,  and  the  cell  proliferation  proceeds  with 
such  rapidity  that  until  parturition  initiates  lactation  the  alveoli 
lose  their  lumen  and  consist  of  solid  cords  of  cells ;  the  breast 
becomes  coarsely  granular  to  the  touch,  the  skin  of  the  areola  dark ; 
and  in  the  later  months  of  pregnancy  a  watery  fluid  exudes  from 
the  nipple. 

The  establishment  of  lactation  is  accompanied  by  general  con- 
gestion and  swelling  of  the  breasts,  and  sometimes  by  local  tender- 
ness and  elevation  of  the  temperature,  and  soreness  in  the  axillae. 
These  activities  may  easily  pass  into  acute  mastitis. 

Involution.- — When  lactation  is  over,  the  vascularity  of  the 
gland  rapidly  diminishes,  and  the  lobules  become  much  reduced  in  size 
and  complexity  by  atrophy  of  their  constituent  alveoli.  These  changes 
make  further  progress  at  the  climacteric.  At  this  time  also  the  fatty 
tissue  of  the  breast  often  atrophies,  while  its  fibrous  tissue,  increasing 
in  amount,  contracts  upon  and  causes  gradual  atrophy  or  even 
complete  disappearance  of  many  of  the  glandular  alveoli.  The 
characteristic  withered  and  flattened  breast  of  old  age  is  thus 
produced. 


AM  A  ST  I A  7 

DEVELOPMENTAL  ABNORMALITIES 

AM  VS'I'I  \     AND     POL1  M  \ST1  A 

In  very  rare  oases  one  or  both  of  the  breasts  arc  eonj^enitally  absent — 
a  condition  known  as  amastia  or  amazia.  A  rudimentary  nipple  is  usually 
present.     The   condition    is   often   associated    with    absence   or    rudimentary 


Fig.  252. — Hypertrophy  of  the  breasts. 

(Beatson,   /'.din.  Med.  /ourtt.,  Dec,  1908.) 

development  of  the  sternal  portion  of  the  great  pectoral  muscle,  and,  less 
commonly,  with  other  malformations. 

Polymastia  is  a  condition  in  which  extra  breasts  or  extra  nipples  are 
present,  usually  below  the  normal  nipple.  A  supernumerary  breast  may 
or  may  not  have  a  nipple,  and  is  usually  functionless,  but  may  secrete  milk 
during  lactation.  Polymastia  is  more  frequent  in  men  than  in  women. 
Mitchell   Bruce,    among  4,000   individuals   examined,   found   47   males   and 


8  THE   BREAST 

14  females  with  supernumerary  nipples.  The  accessory  structures  are 
most  often  found  along  a  line  leading  from  the  axilla  downwards  and 
inwards  to  a  point  a  fow  inches  above  the  umbilicus.  A  case  has  been 
recorded  in  which  five  breasts  were  present,  four  of  them  functional.  The 
fifth  and  lowest  was  median,  and  situated  5  in.  above  the  umbilicus. 
Ohampneys  has  shown  that  during  pregnancy  the  axillary  sebaceous  glands 
frequently  become  enlarged  and  lumpy,  and  that  occasionally  true  milk 
may  be  expressed  from  the  hypertrophied  glands.  Bryant  has  pointed 
out  that  certain  cases  of  carcinoma  resembling  breast  cancer,  but  primary 
in  the  axilla,  may  originate  from  such  abnormal  sebaceous  glands. 

HYPERPLASIA    OR    HYPERTROPHY    OF    THE    BREASTS 

This  is  a  rare  affection  met  with  both  in  single  and  in  married  women, 
and  is  usually  bilateral  (Fig.  252).  In  the  most  marked  cases  the  breasts 
within  a  few  months  may  attain  such  an  enormous  size  that  they  become  a 
serious  encumbrance,  causing  pain,  dyspnoea,  and  palpitation.  In  Esterle's  case, 
quoted  by  Rodman,  they  attained  a  combined  weight  of  30  lb.  within  little 
more  than  three  months.  In  Delfis'  case,  occurring  in  a  pregnant  woman, 
the  mammae  rested  upon  the  thighs  when  the  patient  sat  down.  The 
disease  comes  on  most  frequently  about  puberty,  or  during  pregnancy. 
The  cases  associated  with  pregnancy,  though  more  rapid  in  their  evolution, 
are  favourable  in  this  respect,  that  the  hypertrophy  may  subside  after 
parturition,  whereas  in  other  cases  it  is  permanent  and  usually  progressive. 
The  enlargement  depends  upon  a  general  overgrowth  of  the  fibrous  tissue 
of  the  mammas,  but  in  the  cases  associated  with  pregnancy  true  glandular 
hypertrophy  may  be  present. 

Treatment. — Pressure,  mechanical  support,  and  the  administration 
of  iodides  may  suffice  in  the  milder  cases,  but  the  only  treatment  which  has 
proved  effective  in  well-marked  examples  is  amputation  of  the  breasts.  The 
operation  should  not  be  undertaken  during  pregnancy. 

GYNECOMASTIA 

A  unilateral  or  bilateral  hypertrophic  enlargement  of  the  male  breast 
to  such  a  point  that  it  resembles  the  virgin  breast  of  the  female  is  known 
as  gynecomastia.  It  may  occur  as  part  of  a  general  tendency  to  the 
feminine  type,  in  association  with  a  high  voice,  and  perhaps  with  develop- 
mental defects  in  the  genital  organs.  It  is  said  sometimes  to  follow  removal 
of  the  testicles.  It  may  be  found  in  men  of  full  sexual  development.  Histo- 
logically the  breast  resembles  that  of  the  virgin  female. 

Gynecomastia  probably  predisposes  to  pathological  changes.  Thus,  in 
a  man,  otherwise  normal,  who  presented  a  slight  degree  of  this  condition, 
I  observed  bilateral  chronic  mastitis  owing  to  the  pressure  of  the  braces 
upon  the  gland. 

DISEASES  OF  THE  NIPPLE  AND  AREOLA 

RETRACTION    OF    THE    NIPPLE 

This  condition  is  most  often  due  to  failure  in  the  evolution  of 

the  child's  rudimentary  nipple  towards  the  normal  prominent  adult 

type.     The  nipple  may  be  merely  flattened,  or  may  be  represented 

by  a  funnel-like  concavity  at  the  centre  of  the  areola.     This  con- 


DISEASES   OF   THE    NIPPLE 

dition  is  of  importance  because  it  produces  inability  to  Buckle  and 
favours  sepsis  at  the  orifices  of  the  mi  Ik-ducts.  It  may  thus  become  a 
cause  of  milk  congestion,  acute  mastitis,  and  mammary  abscess. 

Acquired   retraction  <>f  the  nipple  indicates  a   fibrotic  process  in 
the   underlying   breasl    tissue.     It    is  an   important    sign   of  ct 
depending  upon  the  reactive    or   inflammatory  processes  associated 
with    the    growth.     Less    commonly,    retraction    is   associated    with 
Paget' s  disease,  or  depends  upon  scarring,  the  result  <>f  an  al 
or  a  shrivelled  cyst.     Some  authors  incorrectly  state  thai  it  occurs  in 

Chronic   mastitis. 

SIMPLE    ECZEMA    OF    THE    NIPPLE 

May  arise  in  the  course  of  or  apart  from  pregnancy  or  lactation,  and 
may  be  a  cause  of  abscess  of  the  breast.  The  Staphylococcus  pyogenes 
aureus  lias  been  demonstrated  in  the  discharge,  and  may  also  be 
present  in  the  milk  during  lactation. 

Treatment. — Various  ointments  may  be  tried.  Boric,  lead 
subacetatc,  and  mild  mercurial  ointments  are  those  most  often  used. 
If  these  fail  and  Paget's  disease  can  be  excluded,  a  trial  of 
vaccine  treatment  should  be  made  after  bacterial  examination. 

"When  eczema  of  the  nipple  occurs  during  lactation  it  is  best  to 
wean  the  child,  both  on  the  mother's  account,  because  a  mammary 
abscess  is  a  likely  sequel,  and  for  the  child's  sake,  because  the  milk 
is  likely  to  contain  staphylococci.  Only  if  the  eczema  is  very  slight 
in  degree  can  sanction  be  given  for  continued  suckling,  through  a 
nipple  shield.  In  such  circumstances  no  poisonous  ointments  must 
be  prescribed. 

Cracked  nipple  is  the  term  applied  to  a  fissured  condition  of  the 
skin  of  the  nipple,  comparable  to  "  chapped  hands."  It  is  usually 
associated  with  eczema  of  the  nipple,  and  generally  occurs  during 
suckling.     The  treatment  is  £ue  same  as  for  eczema. 

PAPILLOMA    OF    THE   NIPPLE 

This  condition  is  sometimes  met  with,  and  the  papilloma  may 
attain  a  considerable  size.  Owing  to  the  constant  drag  of  the  tumour 
on  loose  tissues,  the  larger  examples  of  these  tumours  are  pedun- 
culated. In  the  course  of  years  the  pedicle  may  become  long  and 
attenuated,  and  pulsation  may  be  felt  in  it.  The  tumour  itself  is 
usually  globular,  and  its  surface  lobulated  and  warty.  Owing  to 
septic  changes  the  tumour  may  exude  an  offensive  serous  discharge 
or  may  ulcerate. 

Treatment. — A  sessile  w^art  of  the  areola  should  be  excised. 
A  pedunculated  wart  should  be  strangulated  by  tying  a  stout  ligature 
round  the  base  of  its  pedicle. 


io  THE    BREAST 

CARCINOMA    OF    THE   NIPPLE 

Carcinoma  of  the  nipple  is  rare.  It  may  be  of  the  squamous- 
celled  or  spheroidal-celled  type.  In  the  latter  case  it  probably 
originates  in  the  sebaceous  glands  of  the  areola.  Early  ulceration 
takes  place,  and  the  disease  then  pursues  a  course  similar  to  that 
of  carcinoma  of  the  mamma   itself. 

SEROUS   DISCHARGE    FROM    THE    NIPPLE 

Serous  discharge  from  the  nipple  may  be  due  to  duct  papilloma 
or  duct  carcinoma.  This  is  the  commonest  cause.  It  may  occur  in 
chronic  mastitis,  apart  from  duct  papilloma — a  fact  easy  to  under- 
stand if  it  be  remembered  how  frequently  cysts  are  formed  in  chronic 
mastitis  if  duct  obstruction  prevents  the  exit  of  the  serous  secretion 
(see  Fig.  254).  In  any  given  case,  however,  it  is  practically  impossible 
to  exclude  the  presence  of  a  small  and  impalpable  duct  papilloma, 
which  may  ultimately  become  carcinomatous.  A  serous  discharge 
may  occasionally  persist  for  years,  unaccompanied  by  any  induration 
of  the  breast,  but  there  is  often  a  very  slight  sector-shaped  indura- 
tion of  one  or  more  of  the  lobes,  only  appreciable  on  ver}r  careful 
examination.     Serous  discharge  is  nearly  always  unilateral. 

Treatment. — Mintz,  in  one  of  his  cases,  obtained  a  cure  of 
three  years'  duration  by  giving  large  doses  of  potassium  iodide.  I 
have  tried  X-rays  without  success.  In  my  opinion,  persistent  serous 
discharge  is  best  treated  by  complete  removal  of  the  breast. 

PAGET'S    DISEASE    OF    THE    NIPPLE 

This  affection  is  a  unilateral  chronic  intractable  eczema  of  the 
nipple,  first  described  by  Paget  as  preceding,  cancer  of  the  mammary 
gland.  The  disease  usually  occurs  in  middle-aged  or  elderly  women, 
very  rarely  in  men.  It  begins  with  an  eruption  on  the  nipple  and 
areoiaTwhich  generally  present  a  florid,  intensely  red,  finely  granulated 
surface  like  that  of  acute  eczema  or  acute  balanitis.  The  surface 
exudes  a  copious  clear,  yellowish  discharge,  and  is  the  seat  of  tingling, 
itching,  and  burning  sensations.  In  other  cases  the  eruption  resembles 
chronic  eczema,  with  minute  vesications,  succeeded  by  moist,  yellowish 
scabs  or  scales,  and  accompanied  by  viscid  exudation.  Sometimes 
it  is  dry,  like  psoriasis,  with  a  few  whitish  scabs  slowly  desquamating. 
Within  a  period  not  usually  exceeding  two  years,  but  possibly  pro- 
longed to  ten  years,  a  carcinomatous  lump  appears  in  the  breast, 
often  at  a  point  remote  from  the  nipple,  and  usually  in  discontinuity 
with  the  eczematous  skin.    (Fig.  253  and  Plate  82.) 

It  should  be  stated  here  that  eczema  of  the  nipple,  according 
to  R.   Williams,  may  persist  as  long    as  twenty  years  without  the 


PAGET'S    DISEASE    OF   THE    NIPPLE 

development  of  a  cancer.    Such  rare  cases  may  be  explained  b 
facts  of  atrophic  scirrhus  [see  \>.  79),  and  they  do  nol  affecl  the  broad 
statement  thai  intractable  eczema  of  the  nipple  is  generally  followed 
clinically  by  the  developmenl  oi  cancer. 

Histological  appearances.-  Tin-  description  besl  borne 
mil  by  my  own  observations  is  that  originally  given  by  Butlin.  The 
mucous  layer  of  the  epidermis  is  much  thickened  from  hyperp 


Fig.  253. — Paget's  disease  of  the  left  nipple.      A   palpable 
carcinoma  was   present   in   the   breast. 

(From  a  case  under  the  writer's  care  at   the  Middlesex  Hospital.) 


and  its  cells  are  vacuolated  and  swollen ;  the 
subcutaneous  tissues,  and  the  tissues  round  the 
with  small,  round,  lymphocyte-like  cells. 


corium,  the  adjacent 
ducts  are  infiltrated" 


TmT 

are  dilated  and  rilled  with  epithelial  cells  and 
ducts  and  acini  may  be  filled  with  epithelium 
thelial  outgrowths  into  the  surrounding  tissues. 
developed  carcinoma  is  seen  at  some  part  or 
The  carcinoma  may  be  a  duct  carcinoma,  and 
a    case    in    which    squamous  -  celled    carcinoma 


galactophorousducts 

debris,  while  smaller 

or  may  exhibit  epi- 

In  other  cases  fully 

other  of  the  breast. 

Butlin  has  recorded 

of    the    nipple    was 


12  THE    BREAST 

associated  with  chronic  eczema,  but  the  growth  is  usually  acinous 
or  spheroidal-celled,  and  accordingly  the  mass  which  it  forms  is 
unconnected  at  first  with  the  eczematous  areola,  from  which  all 
induration  is  absent. 

Pathology  of  Paget's  disease — Darier  in  1889,  sup- 
ported by  Wickham  in  1890,  declared  that  Paget's  disease  was  due 
to  infection  of  the  skin  by  p'sorosperms,  small  parasitic  algse  allied 
to  the  diatoms,  frequently  found  in  the  liver  of  the  rabbit  and 
in  certain  fishes.  Subsequent  observers  have  shown  that  the  sup- 
posed psorosperms  in  the  skin  of  the  areola  are  really  vacuoles  or 
secretion  granules,  or  are  appearances  due  to  the  degeneration  of 
the  epithelial  cells.  The  psorosperm  theory,  abandoned  by  its 
originator,  now  finds  very  few  supporters. 

As  far  back  as  1881,  George  Thin  stated  the  view  that  in  Paget's 
disease — or,  as  he  called  it,  malignant  papillary  dermatitis — a  car- 
cinoma originating  in  the  epithelium  of  the  ducts  near  the  nipple 
was  the  precursor  of  the  changes  in  the  skin  of  the  areola.  He  believed 
the  eczema  to  result  from  the  irritant  discharge  of  the  carcinoma. 
Thin's  view  is  probably  true  in  some  cases,  but  it  is  not  applicable  to 
most,  for  as  a  rule  the  carcinoma  forms  a  lump  in  the  breast  isolated 
from  the  nipple  by  a  considerable  extent  of  clinically  normal  breast 
tissue,  and  is  of  acinous  type. 

Schambacher  (1905)  maintained  that  Paget's  disease  is  a  carcinoma 
originating  within  the  epidermis  and  subsequently  spreading  along 
the  milk-ducts.  This  view  seems  to  be  entirely  negatived  by  the 
absence  of  any  sign  of  neoplastic  overgrowth  in  the  eczematous  skin. 

My  own  views  upon  Paget's  disease  may  be  succinctly  stated 
as  follows  :  A  carcinoma  which  may  be  either  a  duct  carcinoma 
or  one  of  acinous  type  originates  in  the  breast.  Frequently  this 
carcinoma  is  of  a  somewhat  atrophic  variety,  and  it  is  known  that 
an  atrophic  scirrhus  may  be  present  in  the  breast  for  years  without 
producing  any  palpable  lump.  While  still  in  the  impalpable  stage 
the  carcinoma  may  permeate  the  lymphatics  of  the  breast,  many  of 
which  may  be  subsequently  converted  by  fibrosis  into  solid  strands 
of  fibrous  tissue.  Considerable  disturbance  in  the  lymphatic  cir- 
culation results,  especially  in  the  region  of  the  nipple,  which  in  middle- 
aged  women  is  the  most  dependent  part  of  the  breast.  Eczema  of 
the  nipple  is  merely  a  secondary  manifestation  of  impaired  lymphatic 
return  from  the  skin  of  the  areolar  district,  though  it  may  precede 
by  some  years  the  stage  in  which  the  original  carcinoma  can  be  felt 
as  a  definite  lump.  Eczema  as  the  result  of  lymphatic  obstruction 
is  frequently  seen  upon  the  sodden  skin  of  the  leg  in  elephantiasis, 
and  even  venous  obstruction  is  competent  to  produce  a  like  condition, 
as  in  the  common  case  of  varicose  eczema.     The  swelling  and  vacuo- 


CHANCRE   OF   THE    NIPPLE  r3 

lation  of  Mi«'  deeper  layers  of  the  epidermis  of  the  areola  and  the 
round-celled  infiltration  <>f  the  derma  are  to  be  explained  aa  the 
resulta  of  Lymphal  Lc  obal  ruction. 

Diagnosis.  It  a  lump  presenting  the  characters  of  a  carcinoma 
is  already  present,  in  the  breast,  if  the  axillary  glanda  are  bard  and 
enlarged,  or  if  the  nipple  shows  retraction  or  partial  destrucl 
Paget's  disease  cannot  be  mistaken  for  Bimple  eczema  of  the  nipple. 
In  eases  where  such  signs  .are  wanting,  the  failure  of  the  usual  appli- 
cations for  eczema  is  the  foundation  upon  which  a  diagnosis  of  Pac 
disease  must  rest.  While  simple  eczema  of  t  he  nipple  ma  v  he  bilateral 
Paget's  disease  is  a  unilateral  affection. 

""Prognosis. — True  Paget's  disease  is  invariably  associated  with 
carcinoma,  which  usually  manifests  itself  clinically  within  two  y< 
of  the  onset  of  the  eczema.  The  prognosis  is  that  of  cancer  of  the 
breast  in  general,  and  is  favourable  only  when  early  and  complete 
operation  is  performed.  Nevertheless,  the  form  of  cancer  associated 
with  Paget's  disease  often  runs  a  prolonged  course. 

Treatment. — If  dermatological  treatment  fails  to  cure  the 
eczema,  the  case  should  be  treated  as  one  of  cancer  of  the  breast, 
even  if  no  lump  can  be  felt  (see  p.  82).  In  early  cases  it  may  not 
be  thought  necessary  to  ablate  the  pectoral  muscles,  but  if  this  is 
not  done  it  is  extremely  difficult  to  extirpate  the  highest  axillary 
glands  (subclavian  glands).  If  the  history  of  eczema  is  a  long  one 
it  is  safer  to  perform  the  complete  operation  for  carcinoma  (p.  89). 

CHANCRE   OF   THE   NIPPLE 

Primary  chancre  of  the  nipple  is  rarely  seen  in  the  mother  of  a 
syphilitic  infant,  for  either  she  is  immunized  by  a  previous  attack 
of  the  disease,  or,  in  accordance  with  Colles's  law,  the  syphilitic  foetus 
has  protected  its  mother  without  infecting  her.  On  the  other  hand, 
a  wet-nurse,  or  any  woman,  married  or  unmarried,  who  may  casually 
hold  the  child  to  ken  breast,  or  who  in  any  other  way  comes  in  contact 
with  mucous  pw«lSs  ofjpmeTips,  is  liable  to  contract  the  disease. 

A  breast  chancre  is  usually  found  on  the  areola  at  the  base  of 
the  nipple,  but  may  be  situated  on  the  skin  of  the  breast.  Though 
generally  single,  it  may  be  multiple,  and  both  breasts  may  be  affected. 
It  often  fails  to  conform  to  the  type  of  the  characteristic  Hunterian 
chancre.  It  may  present  itself  as  a  non-indurated  and  apparently 
trivial  fissure  or  excoriation,  or  as  a  minute,  rounded  and  slightly 
elevated  induration  covered  by  reddened  skin,  which  subsequently 
ulcerates  at  its  centre.  The  ulcer  gives  rise  to  little  discharge,  and 
may  be  covered  by  a  scab.  In  other  cases  the  base  becomes  sloughy, 
and  phagedena  may  supervene.  Sometimes  the  adjoining  uipple 
becomes    swollen    and    painful.     Soon    the    axillary    glands    become 


14  THE   BREAST 

enlarged  and  hard,  but  they  are  not  tender  nor  do  they  lose  their 
mobility.  The  further  progress  of  the  case  is  that  of  syphilis  (see 
Vol.  I.,  p.  729),  and  the  appearance  of  secondary  symptoms  clears 
up  any  doubt  as  to  the  diagnosis,  if  a  scraping  has  not  already  revealed 
the  presence  of  the  Treponema  pallidum  (Spirochete  pallida). 

Chancre  of  the  nipple  would  appear  to  be  decreasing  in  frequency. 
Owing  to  its  rarity  it  is  apt  to  escape  recognition. 


DISEASES  OF  THE  MAMMARY  GLAND 

ACUTE    MASTITIS 

Acute  mastitis  is  usually  associated  with  the  function  of  lactation. 
This  variety,  therefore,  will  be  first  completely  considered,  and  the 
rarer  ones  will  be  separately  dealt  with. 

The  acute  mastitis  of  lactation  has  for  its  chief  predisposing  cause 
the  condition  known  as  milk  engorgement,  while  its  exciting  cause 
is  the  entrance  of  suppurative  organisms  through  a  crack  or  abrasion 
of  the  nipple  (see  Cracked  Nipple,  p.  9),  or  along  the  milk-ducts. 
Acute  mastitis  may  terminate  by  resolution,  or  may  end  in  mammary 
abscess. 

Milk  engorgement. — During  the  earliest  days  of  lactation 
the  normal  mammary  hyperemia  may  become  excessive.  This  is 
specially  likely  if  the  milk  secreted  is  unable  to  escape.  Some  of 
the  mammary  ducts  from  long  disuse  may  be  partially  blocked  by 
epithelial  debris,  and  in  this  case  the  signs  of  engorgement  may 
be  restricted  to  the  corresponding  lobe  or  lobes  of  the  breast. 
Diffuse  engorgement  of  both  '  breasts  is  usually  associated  with  the 
sudden  cessation  of  lactation,  as  upon  the  death  or  weaning  of  the 
child.  Unilateral  engorgement  commonly  depends  upon  congenital 
retraction  of  the  corresponding  nipple,  with  consequent  inability 
to  suckle  on  the  affected  side.  The  breast  becomes  swollen,  hot, 
tense,  and  painful.  Irregular  branching  areas  of  induration  mark 
out  the  course  of  the  distended  milk-ducts,  while  the  breast  tissue 
itself  takes  on  a  coarse  granular  hardness.  The  superficial  veins 
are  prominent.  The  axillary  glands  may  become  tender  and  some- 
what enlarged.  Headache,  slight  pyrexia,  and  constipation  are  fre- 
quently present.  If  a  portion  only  of  the  breast  is  affected,  the  swelling 
has  a  sector-shaped  outline  corresponding  to  the  shape  of  the  affected 
lobe  or  lobes.  No  sharp  line  of  demarcation  can  be  drawn  between 
milk  engorgement  and  acute  parenchymatous  mastitis  terminating 
in  mammary  abscess,  the  one  condition  passing  imperceptibly  into 
the  other. 

It  is  important  not  to  mistake  mere  engorgement  or  parenchy- 


ACUTE    MASTITIS   OF    LACTATION  is 

matoua  mastitis  for  suppurative   inflammation  of  the   biea  t.     No 
incision  should  be  made  into  the  breast   unless  the  signs  of  ab 
are  definite. 

The  treatment  of  milk  engorgement  is  to  empty  the 
breasts,  to  relieve  pain  and  congestion,  and  to  support  the  heavy  b 
by  a  sling  or  bandage.  The  first  object,  is  best  attained  by  gentle 
massage  directed  from  the  periphery  of  the  breast  towards  the  nipple. 
Rodman  recommends  the  use  of  a  mixture  of  Lanoline  1  part,  and  ben 
zoated  lard  7  parts,  as  a  friction  application,  the  mixture  being  melted 
on  a  water-bath  each  time  it  is  used.  Hot  fomentations  in  the  inter- 
vals of  massage  relieve  pain  and  congestion,  but  are  likely  to  ini 
the  risk  of  suppuration,  and  in  slight  cases  a  cold  evaporating  lotion  is 
better  treatment.  A  mild  purgative  is  given.  If  further  lactation 
is  not  desired,  glycerine  of  belladonna  should  be  applied  to  the  breast 
and  a  course  of  "  white  mixture  "  or  potassium  iodide  ordered.  Lastly, 
and  perhaps  most  important,  the  nipple  must  be  washed  with  boric 
lotions,  and  a  mild  mercurial  ointment  should  be  ordered  if  there 
is  any  crack  or  abrasion,  provided  that  the  breast  is  not  being  used 
for  suckling.  The  breast  must  be  relieved  at  intervals  by  the  cautious 
use  of  the  breast-pump. 

If  any  crack  or  abrasion  is  present  upon  the  nipple  of  an  en- 
gorged breast,  or  if  bacteria  invade  the  milk-ducts,  the  engorgement 
passes  by  imperceptible  degrees  into  a  true  bacterial  inflammation  or 
acute  mastitis.  T.  H.  C.  Benians  has  recently  found  that,  in  a  large 
proportion  of  cases,  Staphylococcus  pyogenes  aureus  is  present  in  pure 
culture.  In  a  certain  number  of  cases,  streptococci,  and  more  rarely 
Staphylococcus  pyogenes  albus,  are  found,  generally  mixed  with  S. 
pyogenes  aureus.  Occasionally  in  puerperal  septicaemia  the  micro- 
organisms may  gain  access  to  the  mammary  gland  by  way  of  the 
blood,  but  mammary  abscess  is  not  a  common  complication  of  puer- 
peral fever. 

Cohn  and  Neumann  find  that  staphylococci  sometimes  occur  in 
the  milk  from  normal  breasts.  If  there  is  obstruction  to  the  milk- 
ducts  the  bacteria  rapidly  increase  in  number,  the  imprisoned  milk 
forming  an  ideal  medium  for  the  multiplication  of  the  bacteria  which 
are  rarely  absent  from  the  region  of  the  nipple.  According  to  Benians 
the  course  of  events  is  as  follows  :  When  suckling  ceases,  staphy- 
lococci multiply  in  the  stagnant  milk,  and  clotting  ensues.  The 
irritation  caused  by  the  milk-clot,  the  bacteria  and  their  products, 
leads  to  invasion  by  leucocytes.  If  these  cells  are  unable  to  destroy 
or  to  render  inert  the  bacteria,  a  mammary  abscess  results. 

The  Staphylococcus  pyogenes  aureus  is  the  usual  cause  of  abscesses 
produced  by  obstruction  to  the  flow  of  milk.  In  cases  where  a  strepto- 
coccus is  found  a  cracked  nipple  is  usually  present,  and  the  infection 


1 6  THE   BREAST 

spreads  from  the  crack,  along  the  lymphatics  of  the  breast,  without 
at  first  causing  obstruction  to  the  flow  of  milk. 

Symptoms  of  acute  mastitis.— Tin  symptoms  of  milk 
engorgement  are  present  in  acute  mastitis  in  a  more  pronounced 
degree  ;  the  breast  becomes  more  tense  and  prominent,  and  a  local 
induration  may  become  evident,  especially  in  the  lower  part  of  the 
gland,  while  the  pyrexia  reaches  103°  or  104°.  Throbbing  pain  and 
often  an  erythematous  blush  are  present.  Such  cases  usually  terminate 
in  abscess,  and  fluctuation  is  soon  to  be  detected  over  the  indurated 
area,  while  one  or  more  rigors  may  occur. 

Treatment  of  acute  mastitis. — Hot  fomentations  should 
be  substituted  for  the  cold  applications  suitable  for  milk  engorge- 
ment, the  infant  should  be  weaned,  and  energetic  measures  taken  to 
stop  the  secretion  of  milk.  The  breast  should  be  carefully  supported 
by  a  bandage,  but  any  severe  degree  of  pressure  is  too  painful  to  be 
borne.     A  careful  watch  must  be  kept  for  signs  of  suppuration. 

Acute  Mammary  Abscess 

Though  acute  mammary  abscess  is  usually  connected  with  lacta- 
tion, this  is  not  invariably  the  case.  Thus,  infantile  or  adolescent 
mastitis,  especially  if  meddlesome  treatment  be  adopted,  may  not 
rarely  terminate  in  abscess.  At  any  age  an  injury  of  the  breast,  with 
or  without  the  formation  of  a  hsematoma  at  the  seat  of  injury,  may 
lead  to  an  abscess.  Occasionally  an  apparently  spontaneous  abscess 
is  met  with  in  the  adult  virgin  breast.  Of  102  consecutive  cases  of 
mammary  abscess  observed  by  Bryant,  79  occurred  during  lactation, 
2  during  pregnancy,  and  21  in  patients  who  were  neither  lactating 
nor  pregnant. 

Abscesses  of  the  breast  are  divided  into  three  classes,  according 
to  their  situation  in  the  organ — (1)  subareolar  or  supramammary 
abscess  ;  (2)  parenchymatous  or  deep  or  intramammary  abscess ; 
(3)  retromammary  abscess.  The  first  two  varieties  are  common,  and 
usually  either  occur  during  the  first  month  of  lactation,  or  follow 
impairment  of  health  by  prolonged  suckling,  or  the  sudden  cessation 
of  lactation.  Retraction  of  the  nipple,  which  interferes  with  the  due 
emptying  of  the  breast  by  suckling,  favours  milk  engorgement  and 
abscess.  The  importance  of  cracks  and  abrasions  upon  the  nipple 
has  already  been  mentioned.  Retromammary  abscess  is  less  closely 
associated  with  lactation. 


1.  In  subareolar  abscess  pus  forms  immediately  beneath  the  skin 
of  the  areola.  Accordingly,  redness  of  the  skin  is  an  early  and  pro- 
minent symptom,  and  fluctuation  is  very  obvious.  The  abscess  is 
smaller  and  causes  less  constitutional  disturbance  than  the  deeper 
varieties  of  suppuration. 


ACUTE    MAMMARY   ABSCESS 

2.  Intramammaty  absoess  is  the  mosl  common  ;in<l  mosl  impoi 
variety.    Owing  to  the  depth  a1   which  the  pus  forms,  fluctuation 
may  be  absent,  01  difficult   to  elicit.     Pus  may  burrow  ezten 
through  the  gland  in  various  directions  before  it  approaches  the  skin. 
Meantime,  constitutional  disturkuiee  is  often  srwiv.  and  tin-  whole 
breast  is  involved  in  oedematous  swelling.    Later,  when  the  al 

is  beginning  to  point,  the  skin  becomes  red  or  mottled.  After  such 
an  abscess,  unless  surgical  treatment  is  careful  and  thorough,  the 
breast  may  be  left  in  a  disorganized  and  useless  condition,  riddled 
by  persistent  sinuses,  and  sometimes  shrunken  and  deformed  by 
cicatrization. 

3.  Retromammary  abscess  is  not  common.  It  may  arise  from 
necrosis  or  tuberculosis  of  a  rib,  from  tuberculosis  of  the  sternum, 
from  an  infected  hematoma,  or  from  suppuration  of  the  deeper 
portions  of  the  breast.  The  collection  of  pus  is  usually  large,  and 
is  situated  between  the  great  pectoral  and  the  deep  surface  of  the 
mamma.  The  breast  is  thrust  prominently  forward,  and  is  found 
to  be  lying  upon  a  fluctuating  cushion  of  pus.  The  skin  of  the  breast 
is  not  reddened.  The  abscess  usually  points  at  the  lower  and  outer 
ma  ruin  of  the  breast. 

Prophylaxis  of  mammary  abscess. — It  is  necessary  to  take 
precautions  against  cracks,  fissures,  or  abrasions  of  the  nipple,  to  keej 
the  nipple  and  the  child's  mouth  in  as  aseptic  a  condition  as  possible, 
and  to  maintain  the  patency  of  the  milk-ducts.  During  pregnancy 
the  nipple  should  be  hardened  by  regularly  rubbing  it  with  alcohol 
(eau-de-Cologne  or  spirit).  After  suckling  the  nipple  must  be  bathed 
with  boric  lotion  and  then  carefully  dried,  and  the  infant's  mouth 
cleansed  with  a  rag  dipped  in  the  same  lotion. 

Treatment  of  mammary  abscess. — The  abscess,  if  subareolar 
or  intramammary,  must  be  opened  at  the  earliest  possible  moment  by  a 
free  incision,  which,  in  order  to  avoid  cutting  the  milk-ducts,  should 
radiate  from  the  nipple.  The  ringer  should  be  introduced  into  the 
cavity,  and  all  septa  found  traversing  it  should  be  broken  down  so 
as  to  ensure  free  drainage.  A  rubber  tube  should  be  left  in  the  cavity, 
and  careful  watch  kept  for  burrowing  or  pocketing  of  pus  in  new 
directions.     A  dry  gauze  dressing,  changed  daily,  may  be  applied. 

If  any  signs  of  burrowing  appear,  a  director  must  be  passed  in 
various  directions,  and  the  pockets  must  either  be  slit  up  along  their 
whole  length,  or  opened  and  drained  by  tubes  at  the  most  dependent 
points. 

Constitutional  and  general  treatment  will  vary  according  to  the 
nature  of  the  abscess.  Lactation  must  be  stopped  either  by  the 
regular  administration  of  white  mixture,  or  of  saline  purgatives  in 
other  combinations,  or  by  giving  potassium  iodide  in  doses  of  5-10  gr. 


18  THE   BREAST 

thrice  daily.  At  the  Bame  time  glycerine  of  belladonna  is  applied 
to  both  breasts,  which  are  then  to  be  firmly  bandaged  over  a  layer  of 
wool.  If  the  patient  is  exhausted  by  long  lactation  a  more  tonic 
treatment  is  necessary.  Saline  purgatives  must  be  replaced  by  iron 
and  strychnine,  and  a  generous  diet  prescribed,  while  a  glass  of  bur- 
gundy with  lunch  and  dinner  may  be  of  advantage  after  the  flow 
of  milk  has  ceased. 

Retromammary  abscess  is  best  opened  by  an  incision  situated  in 
the  sulcus  beneath  the  breast  and  at  its  lower  and  outer  margin. 
Search  should  be  made  at  the  operation  for  bare  bone,  and  for  an 
opening  communicating  with  the  thoracic  cavity. 

Mammary  abscess  due  to  tubercle,  actinomycosis,  or  syphilis  will 
be  referred  to  under  the  heads  of  those  diseases.  Abscess  may  result 
from  hydatid  disease  of  the  breast.  , 

Bier's  hyperaemia  in  acute  mastitis.— Bier  recommends 
the  treatment  of  acute  mastitis  in  all  its  stages  by  a  dome- 
shaped  cupping  glass,  of  a  diameter  about  an  inch  smaller  than  the 
mammary  gland  itself,  and  with  a  margin  curved  to  fit  the  chest 
wall.  Air  is  cautiously  withdrawn  by  a  suction  syringe  ;  the  breast 
protrudes  into  the  bell  and  becomes  blue  and  engorged.  "When  the 
patient  finally  feels  as  if  the  breast  would  burst,  the  exhaustion  of 
air  should  be  stopped,  for  the  entire  procedure  should  be  painless. 
Usually  one  or  two  ounces  of  milk  escape.  Abscesses  and  sinuses, 
which  at  first  discharge  blood  and  pus,  yield  only  blood-stained  serous 
fluid  towards  the  end  of  the  sitting.  If  pain  is  not  relieved,  an  abscess 
must  be  suspected,  and  should  be  opened  by  a  small  incision,  the 
patency  of  which  must  be  maintained  by  a  drainage-tube.  Large 
incisions  are  said  to  be  unnecessary  when  Bier's  treatment  is  used. 
The  glass  is  to  be  applied  for  forty-five  minutes  daily,  suction  for  five 
minutes  alternating  with  release  of  pressure  for  three  minutes.  When 
suppuration  ceases  the  duration  of  the  daily  sitting  may  be  lessened. 

Vaccine  treatment  of  acute  mastitis. — The  vaccine 
treatment  of  acute  mastitis  and  mammary  abscess  is  so  recent  that 
it  is  not  yet  possible  to  estimate  its  value.  In  acute  mastitis  where 
suppuration  threatens,  if  a  cracked  nipple  is  present,  a  vaccine  may 
be  prepared  from  the  organisms  found  in  the  crack,  and  by  its  prompt 
use  the  formation  of  an  abscess  may  be  averted.  If  streptococci  are 
seen  in  a  stained  film,  a  stock  vaccine  may  be  used  without  waiting 
for  a  cultivation. 

In  cases  of  acute  mastitis  where  no  cracked  nipple  is  present, 
the  Staphylococcus  pyogenes  aureus  is  probably  the  infecting  agent. 
It  is  accordingly  reasonable  to  endeavour  to  avert  suppuration  by 
injections  of  a  stock  vaccine  of  this  organism  in  doses  of  100-500 
millions  at  intervals  of  a  week. 


CHRONIC    M  \s  I  l  I  is  19 

If  suppuration  has  already  occurred  fche  pus  musl   be  lei  01 
incision.     The  value  of  vaccine  treatmenl  during  the  acute    I 
doubt  ful. 

hi  cases  where  sinuses  persist,  usually  as  the  result  of  inadequate 
surgical  treatment,  vaccine  treatmenl  appears  i<>  be  of  great  value. 
The  treat  incut-  slum  M  con  sisi  hi  the  weekly  injection  of  WO  800  millions 
of  S.  aureus  in  stock  vaccine,  controlled,  if  the  case  does  not  rapidly 
yield,  by  cultivations  which  may  show  1  he  presence  of  o1  her  organisms. 
In  such  cases  an  autogenous  vaccine  is  prepared  for  use. 

CHKONIC    .MASTITIS 
In  women  who  have  readied  or  passed  middle  life  the   brea 

or  portions  of  them,  are  very  liable  to  undergo  certain  fibroid  changes, 
associated  either  with  hypertrophy  or  with  atrophy  of  the  secreting 
epithelium.  The  condition  is  known  as  chronic  mastitis  or  chronic, 
lobular  mastitis.  According  to  the  condition  of  the  epithelium,  two 
forms  may  be  recognized — hypertrophic  mastitis  and  atrophic  mastitis. 
Chronic  mastitis  is  a  frequent  precursor  of  breast  cancer  (see  p.  50),' 
and  owes  its  chief  importance  to  this  fact  and  to  its  clinical  resem- 
blances to  cancer. 

Etiology — Chronic  mastitis  may  occur  at  any  age  after  puberty 
It  is  not  very  rare  in  young  unmarried  women,  and  its  frequency 
probably  increases  up  to  a  maximum  at  the  menopause,  the  agenear 
which  a  large  maioritv  of  the  cases  occur.  Some  authors  state  that 
it  is  more  common  among  married  women,  but  my  own  experience 
indicates  a  greater  frequency  in  the  unmarried. 

The  onset  of  chronic  mastitis  is  sometimes  determined  by  a  blow. 
Lenthal  Cheatle  has  recently  brought  forward  strong  reasons  to  believe 
that  the  pressure  of  ill-fitting  corsets,  and  more  especially  the  impaling 
of  the  breast  upon  the  upper  end  of  a  stay-bone,  may  induce  local 
mastitis  at  the  seat  of  pressure. 

Chronic  mastitis  is  most  frequently  seen  in  the  axillary  tail,  and 
in  tli e  portion  of  the  breast  immediately  adjoining,  but  may  occ ur  in 
any  part  of  the  breast. 

It  may  be  regarded  as  a  morbid  deviation  in  the  normal  physio- 
logical processes  of  evolution  and  involution  which  correspond  with 
the  sexual  crises  of  a  woman's  life — puberty,  menstruation,  pregnane}-, 
lactation,  and  the  menopause.  Apart  from  these  physiological  tides 
of  tissue  change,  mild  bacterial  invasion  and  obstruction  of  the  ducts 
may  play  a  part,  though  Lenthal  Cheatle's  researches  go  to  show 
that  the  disease  is  not  dependent  on  bacterial  infection. 

Naked-eye    anatomy    of   chronic    mastitis. — A  hi 
the  seat  of  marked  chronic  mastitis,  when  cut  across,  is  tough  and 
*'  indiarubberv  "   in   consistence,   and   has  not  the  inelastic   hai 


THE    BREAST 


of  a  typical  carcinoma.  Its  colour  is  whitish  or  yellowish,  with  a 
trace  of  pink,  but  without  the  grey  tones  usually  seen  in  a  carcinoma. 
Small  cysts  containing  clear  or  brownish  fluid  are  sometimes  a  pro- 
minent feature.  In  some  cases  these  cysts  attain  exceptional  develop- 
ment and  cause  a  considerable  increase  in  the  size  of  the  breast.  To 
this  condition  the  name  "  cystic  disease  of  the  breast  "  has  been  given, 
but  it  differs  in  no  essential  respect  from  chronic  mastitis  (Fig.  254). 
Histological  changes. — In  the  hypertrophic  form  of  chronic 
_  mastitis     the     lobules 


are  much  increased  in 
size  by  proliferation  of 
their  constituent  acini 
(Fig.  255).  Though 
this  is  the  most  im- 
portant change,  it  is 
not  the  earliest.  The 
epithelial  hypertrophy 
is  preceded  by  changes 
in  the  lobular  and 
peri-acinous  connective 
tissue.  The  lobular 
connective  tissue  is 
swollen  and  increased 
in  amount,  and  the 
connective-tissue 
sheath  of  each  acinus 
becomes  thickened  and 
unduly  cellular,  and  is 
the  seat  of  a  round- 
celled  infiltration  of 
varying  degree.  The 
elastic  tissue  around 
the  ducts  tends  to 
disappear.  Later  the 
richly  cellular  peri- 
acinous  connective 
tissue  undergoes  the  usual  transformation  of  young  fibrous  tissue, 
and  changes  into  characteristic  rings  of  homogeneous  fibrous  tissue 
almost  free  from  nuclei.  The  interlobular  tissue  also  undergoes  a 
fibroid  change,  and  much  of  the  fat  disappears. 

Atrophic  chronic  mastitis  (fibroid  breast)  appears  to  be  a  late 
stage  of  the  hypertrophic  variety.  In  this  form  a  microscopic- 
section  shows  dense  and  old  fibrous  tissue,  poor  in  nuclei.  Em- 
bedded here  and  there   in   the  fibrous  tissue,  islets  of    fat  cells  still 


Fig. 


254. — Cystic  chronic  mastitis 
disease  of  the  breast). 


(cystic 


{From  a  specimen  in  the  Middlesex  Hospital  Museum.) 


CIIKO.MC    M  \S  I  II  IS 


" 


.•; 


remain.    The  lobules  (groups  of  acini)  which  have  escaped  destruction 
are  small,  few  in   number,  and   widely  scattered.     The  epithelium  "i 

i  he  acini  is  Ear  advanced 
in  degeneration,  and  i 

lie  represented  l>v 

shrunken      cells,      often 

Lacking  a  central  Lumen, 
in-    merely    by    a     Little 

mass  Ml  debris  (  Fig 
257). 

Symptoms.     Many 
women      present     some 
degree    of    chronic   mas- 
■•'. .    ;   .'  litis  without  any  corre 

•-ponding  symptoms.     In 

"'■*  other     cases,      however, 

pain     is     a     prominent 

symptom — usually  a  dull 

•'•  «,t>   ■„•   ■-<-  ache,     but     occasionally 

very  severe,  lancinating 
or  neuralgic  in  charac- 
ter, and  very  intractable. 
The  pain  may  be  worse, 
and  the  swelling  more 
marked,  during  the  men- 
strual periods.  It  is  often  aggravated  by  movements,  and  espe- 
cially by  the  prolonged 

: .  ?  & 


Fig.  255. — Hypertrophic  mastitis.  Note  the 
increase  in  size  of  the  lobules.  At  the 
lower  margin  of  the  figure  the  edge 
of  an  infiltrating  carcinoma  can  be 
seen — a  condition  into  which  hyper- 
trophic mastitis  may  readily  pass. 


use  of  the  arm  or  by 
jolting  movements  such 
as  descending  stairs. 

Discharge  from 
the  nipple.  —  The 
frequent  presence  of 
tense  cysts  in  chronic 
mastitis      shows     that 


there  is  considerable  se- 


•v> 


& 


■V 


* 


v 


*%•  ** 


cretorv  pressure  w  it  Inn 
the  gland.     It  is,  there- 


J> 


it    V*5^ 


M 


& 


4 


Fig.  256. — Microscopic  appearances  of  atro- 
phic mastitis.  Note  the  atrophy  of  the 
lobules,  the  increase  of  fibrous  tissue,  and 
the  disappearance  of  the  interlobular  fat. 


fore,  not  surprising  that 

a  serous  discharge  from 

the   nipple    appears   in 

certain  cases  in  which 

obstruction  of  the  ducts  is  incomplete.     The  discharge  may  be  made 

to    flow    by    pressure    upon   the   affected    portion   of   the   gland.     It 


THE   BREAST 


emanates  from  the  particular  orifice  upon  the  nipple  which  corresponds 
to  the  diseased  lobe  of  the  gland.  Such  cases  are  often  very  difficult 
to  distinguish  from  early  examples  of  duct  papilloma.  Fortunately 
the  doubt  in  diagnosis  makes  no  difference  as  regards  treatment  ;  for 
it  is  a  rule  to  which,  in  my  opinion,  there  are  no  exceptions,  that 
stent  serous  discharge  from  the  nipple  in  a  woman  of  middle 
age  should  be  the  signal  for  excision  of  the  breast. 

Physical  signs. — 
There   is   a  granular   in- 
\  duration    of    the    whole 

•      . ,  or    part     of    the    breast 

tissue,  only  vaguely  felt 
when  the  breast  is  com- 
pressed between  the  flat 
hand  and  the  pectoral 
muscle,  but  assuming  the 
characters  of  a  definite 
tumour  when  the  breast 
is  compressed  laterally 
between  the  thumb  and 
fingers .  When  c  y  B  t  i  c 
changes  are  present  the 
cysts  usually  feel  solid, 
and  the  breast  feels  more 
coarsely  granular.  Al- 
though it  is  often  stated 
that  retraction  of  the 
nipple  and  adhesion  of 
the  -kin  may  occur  in 
chronic  mastitis,  the  pre- 
sence of  these  signs  should  give  rise  to  the  gravest  suspicion  of 
malignant  disease.  Xor  is  adhesion  of  the  breast  to  the  pectoral 
fascia  ever  seen  in  chronic  mastitis. 

Atrophic  chronic  mastitis  involving  the  whole  breast  may  reduce 
the  crland  to  a  firm.  ':  rubberv."  hkrklv  convex  disc,  with  thick  rounded 
edges,  resembling  in  shape  the  end  of  a  lemon,  and  not  exceeding 
2  in.  in  diameter.  This  condition  is  only  found  as  the  menopause 
is  approached.  It  is  due  to  fibrous  change  retracting  all  the  lobes 
towards  the  nipple,  their  common  point  of  attachment.  It  must  be 
remembered  that  an  abscess  may  leave  a  palpable  fibrous  art 
the  breast,  adherent  to  the  skin  at  the  point  where  the  abscess  burst. 
Sector-shaped  indurations. — In  many  cases  the  area  of  indura- 
tion is  sector-shaped.  In  doubtful  cases  I  have  come  to  rely  more 
upon  this  sector-shaped  induration  in  the  diagnosis  of  chronic  n. 


*V  .->v 


■ 

4      ' 


Fig.  2.37. — Advanced  atrophic  mastitis  or 
fibroid  breast.  The  lobular  epithelium 
has  almost  disappeared,  but  a  few  dark 
rings  indicate  remains  of  epithelium. 
On  the  right  is  seen  fat  undergoing 
fibroid  change. 


CHRONIC    MASTITIS 

than  upon  any  other  point.     The  b  made  up  <>f  a  num 

sector-shaped   Lobes  which  are   practically   independent    oi 
opening  upon  the  summit  of  the  nipple  by  the  separate  orifice  ol 
own  proper  duct.     Very   frequently  chronic   mastitis  affects  one  of 
the  lobes  alone,  or  several  adjoining  ones,  while  the  real  of  the  bn 
remains  uormal  and  unaffected. 

It  will  be  observed  thai  these  facts  supply  a  most  important  n 
of  distinct  inn  between  chronic  mastitis  and  malignanl  disease.  It  is 
a  characteristic  feature  of  carcinoma  tliat_it  has  little  or  no  reap 
for  anatomical  boundaries.  If  a  carcinoma  Btarts  at  one  point  in  the 
breast  it  will  not  remain  confined  strictly  to  the  lobe  in  which  it 
originated,  but  will  infiltrate  the  surrounding  tissues  in  a  more  or 
less  centrifugal  manner,  producing  a  rounded  lump  which  has  no 
relation  to  the  anatomical  shape  of  the  particular  lobe  in  which  the 
growth  originated. 

Sometimes  the  breast  contains  two  or  more  non-contiguous  sector- 
shaped  areas  of  induration,  while  in  other  cases,  of  course,  the  whole 
breast  presents  an  indefinite  induration. 

It  must,  however,  be  remembered,  in  respect  to  this  important 
physical  sign,  that  it  does  not  exclude  the  possibility  that  an  early 
carcinoma  is  present  within  the  sector-shaped  area.  If,  however,  the 
area  of  induration  is  uniformly  and  finely  granular,  without  any 
localized  lump  or  induration,  this  unpleasant  possibility  may  be 
excluded  almost  with  certainty. 

Chronic  mastitis  and  fibroadenoma — Areas  of  chronic  mas- 
titis are  not  infrequently  met  with  in  the  immediate  neighbourhood  of  a 
fibro-adenoma,  giving  to  the  smooth  surface  of  the  tumour  a  rough, 
granular  feeling.  The  pathology  of  such  areas  is  not  difficult  to  fathom 
if  it  be  borne  in  mind  that  a  fibro-adenoma  often  arises  in  connexion 
with,  and  necessarily  obstructs,  one  of  the  ducts  of  the  breast.  The 
acini  which  open  into  this  particular  duct,  having  no  outlet,  undergo 
the  usual  changes  of  chronic  mastitis.  It  is  often  exceedingly  difficult 
to  differentiate  a  fibro-adenoma,  thus  obscured  by  surrounding  chronic 
mastitis,  from  a  carcinoma.  I  have  most  frequently  met  with  such 
fibro-adenomas  in  or  near  the  axillary  tail  of  the  breast. 

F.  T.  Paul  has,  moreover,  shown  that  a  fibro-adenoma  may 
originate  in  an  area  of  pre-existing  chronic  mastitis  by  the  over- 
growth of  the  connective  tissue  of  one  particular  lobule  of  the  affected 
area.  Thus  fibro-adenoma  may  be  either  a  cause  or  a  consequence 
of  chronic  mastitis. 

Chronic  mastitis  in  duct  papilloma.— In  another  condition 
chronic  mastitis  may  arise  from  obstruction  of  the  ducts,  namely, 
duct  papilloma.  When  a  duct  papilloma  obstructs  one  of  the  large 
ducts  near  the  nipple  the  corresponding  lobe  is  often  mapped  out 


24  THE   BREAST 

as  a  vague,  sector-shaped  induration.  Pressure  upon  the  indurated 
area  often  causes  serous  fluid  to  exude,  or  even  squirt,  from  the 
affected  duct,  while  pressure  upon  the  normal  portions  of  the  breast 
has  no  effect. 

Enlargement  of  the  axillary  glands. — It  is  not  uncommon  to 
find  in  chronic  mastitis  that  the  axillary  glands  are  unduly  palpable — 
that  is  to  say,  they  are  slightly  but  not  much  enlarged.  The  glands 
are  firm  and  elastic,  and  sometimes  tender.  The  slight  degree  of 
enlargement,  the  tenderness,  and  the  absence  of  hardness  help  to 
distinguish  them  from  secondary  carcinomatous  glands. 

Bonney  has  drawn  attention  to  the  precarcinomatous  changes 
which  occur  in  lymphatic  glands.  When  a  cancer  is  present,  e.g.  in 
the  breast,  the  axillary  glands  become  enlarged,  owing  to  the  appear- 
ance of  large  and  active  germinal  areas,  to  an  increase  in  the  number 
of  lymphocytes,  and  to  the  appearance  in  the  gland  of  large  quantities 
of  plasma  cells.  All  these  changes,  according  to  Bonney,  occur  before 
any  malignant  cells  have  reached  the  gland.  In  a  less  degree  he  found 
the  same  changes  in  the  axillary  glands  of  ten  breasts  removed  for 
chronic  mastitis  and  proved  microscopically  to  be  free  from  cancer. 

A  consideration  of  these  facts  makes  it  seem  likely  that  cases  of 
chronic  mastitis  in  which  the  glands  are  unduly  palpable  are  more 
likely  to  end  in  cancer  than  are  those  in  which  this  sign  is  absent.  In 
such -cases  removal  of  the  breast  may  be  the  best  course  to  pursue, 
but  no  general  rule  can  be  laid  down. 

Diagnosis. — The  indurations  of  chronic  mastitis  are  charac- 
terized by  their  vague  definition  when  palpated  by  the  flat  hand, 
thus  differingTrom  both  simple  and  malignant  tumours!  The  sector- 
shape  of  the  indurations  is  also  characteristic  when  only  part  of  the 
breast  is  involved.  Moreover,  as  further  distinctions  from  carcinoma, 
nipple  retraction  and  adhesion  to  skin  and  fascia  are  absent.  A 
carcinomatous  lump  in  the_breast  is  usually  single,  whJKTthe  indura- 
tions of  chronic  mastitis  are  often  multiple.  The  axillary  glands 
are  softish,  elastic,  possibly  tender,  and  not  much  enlarged,  while 
The  glands  in  carcinoma  are  hard,  painless,  and  often  much  increased 
in  size"  If  a  hardness  is  present  in  the  area  of  ill-defined  induration, 
it  may  be  impossible  to  say  without  operation  whether  a  carcinoma 
or  a  simple  cyst  is  the  cause  (Fig.  258),  for  it  must  not  be  forgotten 
that  a  carcinoma  may  arise  in  a  pre-existing  area  of  mastitis. 

Prognosis.  —  In  young  women,  chronic  mastitis  is  tractable 
and  not  dangerous  ;  but  as  the  menopause  is  approached,  a  more 
guarded  prognosis  and  a  closer  watch  become  necessary  in  view  of 
the  intimate  relations  between  chronic  mastitis  and  cancer. 

Treatment. — In  some  cases  of  chronic  mastitis,  especially  in 
young  women,  the  usual  medicinal  treatment  is  satisfactory.     The 


CIIKOMC    MASTITIS:    TKKATMENT 


means  employed  comprise  (a)  pressure  applied  by  means  oi  v 

or  less  effectively  by  bandages  (massage  is  no!  advisable);  (6)inhibi  ** 
turn  of  the  secretory  activity  of  the  epithelium  by  belladonna  and 
iodides  ;  (c)  the  administration  of  drugs  which  promote  the  absorption  *^ 
of  inflammatory  infiltrations,  especially  mercury  and  the  iodides.  I 
im  m it  aware  thai  fibrolysin  lias  Ween  tried  in  mastitis,  and  the  use 
of  this  drug  for  other  conditions  seems  not  absolutely  free  Erom 
danger.  The  old-fashioned  emp.  hydrarg.  c.  ammoniaco,  renewed 
weekly,  is  a  valuable  application,  but  is  liable  to  cause  eczematous 
irritation  of  the  skin.  This  risk  can  lie  minimized  by  antiseptic 
cleansing  of  the  skin  before  the  plaster  is  applied.  Another  method 
of  using  mercury  is  to 
apply  Scott's  ointment, 
diluted  if  necessary,  and 
to  secure  pressure  at  the 
same  time  by  means  of 
strapping.  Iodides  may 
be  applied  locally  in  the 
form  of  the  lin.  pot.  iod. 
c.  sapone,  a  very  clean 
and  pleasant  preparation, 
but  not,  in  my  belief,  a 
very  effective  one.  Bella- 
donna may  be  used  as 
the  glycerinum  or  un- 
guentum,  combined,  if 
necessary,  with  a  mer- 
curial ointment.  It  is 
especially  valuable  where 
pain  is  a  prominent 
symptom. 

But  in  numerous  in- 
stances, more  especially  in  climacteric  mastitis,  drug  treatment  seems 
to  have  no  effect.  In  such  cases,  removal  of  the  breast  is  often 
justifiable.  F.  T.  Paul  says  : — "  I  am  no  advocate  for  the  removal 
of  the  breast  for  mastitis  in  young  women  .  .  .  but  as  regards  the 
involution  period,  I  strongly  maintain  that  amputation  is  indicated 
in  all  cases  of  unyielding  or  very  marked,  and  especially  bilateral, 
chronic  mastitis." 

There  can  be  no  doubt  that  such  a  course  is  the  safest.  But 
removal  of  the  breast,  although  not  in  itself  a  severe  or  dangerous 
operation,  is  a  measure  to  which  few  women  will  consent  unless  the 
risk  of  cancer  is  immediate  and  great.  Moreover,  there  are  numerous 
clear    cases    of    chronic    mastitis   in   which  cancer  can  be  definitely 


Fig.  258. — A  breast,  the  seat  of  chronic 
mastitis  and  containing  a  single  cyst. 
The  case  simulated  a  carcinoma,  and 
the  breast  was  therefore  removed. 

( l-'rom   St.    Thomas's  Hospital  Museum.  I 


26  THE   BREAST 

excluded,  even  in  women  who  have  reached  the  cancer  age.  In 
such  cases  1  do  not  advise  operation. 

Tims,  deducting  the  cases  where  drug  treatmenl  is  successful 
and  those  threatening  or  doubtful  tines  where  operation  is  clearly 
indicated,  there  remains  a  considerable  residue  of  cases  for  which 
hitherto  no  very  hopeful  treatment  has  been  available. 

In  such  cases,  during  the  past  few  years,  I  have  recommended 
a  short  course  of  X-rays  as  a  sedative  to  epithelial  activity  and 
a  prophylactic  against  cancer.  So  far,  in  none  of  the  cases  thus 
treated  has  cancer  subsequently  developed.  But  the  number  of 
cases  treated  is  too  small  to  make  the  evidence  conclusive. 

With  regartl  to  the  clinically  appreciable  effects  of  X-rays  in 
chronic  mastitis,  my  experience  is  at  present  recent  and  restricted ; 
but  on  more  than  one  occasion  after  their  use  I  have  seen  indurations 
of  the  breast  clear  up  or  become  almost  inappreciable.  Sometimes, 
on  the  other  hand,  the  induration  remains  unaltered. 

The  following  is  the  first  case  in  which  I  used  X-rays  for  chronic 
mastitis  : — 

M.  F..  set  43.  attended  the  Middlesex  Hospital  in  March,  1906,  com- 
plaining of  pain  and  induration  in  the  left  breast.  There  was  marked, 
though  indefinite,  induration  of  the  breast,  extending  to  its  axillary  tail. 
On  October  3rd.  1906.  I  asked  Mr.  C.  R.  C.  Lyster  to  give  the  breast  six 
X-ray  exposures  of  ten  minutes  each.  The  exposures  were  completed  by 
October  17th.  Up  to  October  15th  the  pain  was  aggravated,  and  on 
the  17th  no  palpable  change  could  be  detected  in  the  breast.  On  October 
31st,  however,  a  striking  change  was  manifest,  for  the  left  breast,  instead 
of  being  more  indurated  than  the  right  one.  was  distinctly  softer.  The 
patient,  however,  still  complained  of  pain  in  the  axillary  tail  of  the  left 
breast,  and  in  this  situation  some  induration  remained.  On  October  31st 
I  asked  Mr.  Lyster  to  give  six  exposures  to  the  axilla,  so  as  to  reach  the 
axillary  tail,  which  is,  of  course,  protected  by  the  great  pectoral  when  the 
arm  is  lying  close  to  the  chest.  On  December  10th,  1906,  no  lumpiness 
could  be  detected  in  either  breast.  The  patient  complained  of  pains  in 
the  arms  and  head,  but  not  in  the  breasts.  This  patient  was  seen  again 
in  February.  1909.  about  three  years  after  her  first  visit.  The  breasts, 
though  somewhat  fibroid,  were  quite  free  from  localized  indurations,  and 
were  practically  normal.  The  cure  may  be  presumed,  therefore,  to  be  a 
permanent  one.     The  left  breast  is  slightly  smaller  than  the  right. 

Further  experience  has  confirmed  my  belief  in  the  value  of  X-rays 
in  chronic  mastitis. 

TUBERCULOUS    MASTITIS 

Tuberculosis  of  the  breast  is  rare,  accounting  for  only  about  1  per 
cent,  of  hospital  admissions  for  mammary  disease.  More  than  half 
the  cases  occur  between  the  ages  of  25  and  35,  and  very_few  indeed 
after  the  menopause,  though  even  old  age  is  not  exempt.  The 
affection  is~usuallv  unilateral     It  mav  Tdfm  the  onlv  discoverable 


Tl    III   KCl    LOUS    MASTITIS 


*7 


tuberculous  focus  presenl  in  the  body,  but  in  50  per  cent,  "i 
it    is  Becondary   to  tuberculosis   elsewhere,   as,    for   instance,   in   the 
supraclavicular  or  axillary  glands,  or  in  the  Lungs.     Infection  prob- 
ably usually  occurs  through  the  blood-stream  or  by  direct  ext< 
from  tli<-  adjoining  ribs  or  pleura.     Bui    it    is   not    rare   for  tuber- 
culosis of  the  cervical  glands  to  extend  downwards  t<>  the  axillary 
L'lan<!-.  and  a  continuance  of  the  same  process  of  retrograde  infection 
along  the  lymphatics  to  the  breast  may  be  responsible  for  somi 
of  mammary  tubercle,     It  is  also  possible  that  direct  infection  along 
the  ducts  1 1 < >m  the  nipple  may  in  some  cases  take  place.     In  one 

orded  case  the  disease  l>«'<j.-m  as  an  ulceration  of  the  nipple. 

Morbid  anatomy. — Miliary  tubercles  maybe  scattered  through 
th»>  breasts  in  cases  of 
general  tuberculosis,  but 
this  form  of  the  disease 
possesses  no  separate  im- 
portance. In  tuberculous 
mastitis  the  breast  in 
section  presents  multiple 
caseating  foci,  separated 
by  fibrotic  areas,  and  areas 
of  healthy  tissue.  Later, 
these  caseating  areas  tend 
to  coalesce  and  break 
down,  and  one  or  more 
abscesses,  lined  by  pale 
and  flabby  granulations 
and  containing  caseous 
pus,  may  be  formed.  These 

abscesses,   after   breaking 

,    '  ,  .         ,    •   i     Fig.  259. — Tubercle  of  the  breast.    A  lobule 

through  the  skin,  shrink  *  Khnvaintr  Mrlv  tuberculous  change  occu- 
into  chronic  sinuses,  and 
in  the  latest  stage  the 
breast  becomes  a  fibrous 
relic,  riddled  in  all  di- 
rections by  tuberculous 
sinuses. 

Microscopic  ana- 
tomy. —  In    its    earliest 

stage,  tuberculosis  of  the  breast  presents  itself  microscopically  in  the 
form  of  dense  masses  of  lymphocyte-like  cells  around  the  acini  and 
along  the  course  of  the  smaller  ducts.  The  collection  of  round  cells 
lies  outside  the  layer  of  fibrous  tissue  which  immediately  surrounds 
the  epithelium.    Giant-cell  systems  may  be  absent.    (Mg.  259.)    As  the 


showing  early  tuberculous  change  occu- 
pies almost  the  whole  field.  The  pic- 
ture appears  confused,  but  careful  ob- 
servation will  show  as  characteristic 
points — [a)  the  quiet  disappearance  of 
the  epithelium;  (b)  the  formation  of  a 
ring  of  granulation  tissue  round  each 
acinus  ;  (c)  the  absence  of  giant  cells, 
which  appear  later  in  the  disease. 


28  THE   BREAST 

areas  of  round  cells  increase  in  density  the  epithelial  structures  quietly 
atrophy  and  disappear,  leaving  a  mass  of  tuberculous  granulation 
tissue  in  which  typical  giant  cells  can  now  be  recognized.  This  granu- 
lation tissue  may  undergo  fibrosis  or  caseation,  or  from  its  liquefaction 
one  or  more  abscesses  of  considerable  size  and  lined  by  tuberculous 
granulations  may  be  formed.  The  areas'  of  fat  intervening  between 
the  mammary  lobules  undergo  fibrous  degeneration. 

If  a  large  abscess  is  formed,  the  overlying  skin  may  show  the  clinical 
appearance  of  peau  d'orange,  and  as  seen  microscopically  it  may  pre- 
sent the  dermal  thickening  which  indicates  lymphatic  obstruction. 

Clinical  features. — The  first  sign  is  the  appearance  in  the 
breast  of  one  or  more  vague  indurations,  indistinguishable  from  simple 
chronic  mastitis.  It  is  important  to  note  that  more  than  one  indurated 
area  is  usually  present  in  the  affected  breast.  As  the  case  progresses 
more  massive  indurations  are  formed,  palpable  with  the  flat  hand, 
and  suggestive  of  malignant  disease.  This  similarity  may  be  increased 
by  the  presence  of  enlarged  tuberculous  axillary  glands,  and  by  the 
adhesion  of  the  mass  to  the  skin  and  to  the  underlying  fascia.  The 
overlying  skin  may  assume  the  characteristic  orange-rind  appearance. 
But  soon  after  adhesion  to  the  skin  has  occurred  a  soft  central  patch 
becomes  evident  in  the  indurated  mass.  The  skin  at  this  point 
becomes  thin  and  reddened,  and  an  abscess  points  and  bursts,  leaving 
a  persistent  sinus  with  pale  flabby  granulations  at  its  entrance,  dis- 
charging thin  pus  containing  caseous  debris. 

Cold  abscess  of  the  breast  presents  itself  as  a  cystic  swelling  with 
a  tendency  to  become  adherent  to  the  skin.  It  is  usually  of  tuber- 
culous origin.  Tuberculous  submammary  abscess  is  met  with  as  the 
result  of  tubercle  of  the  ribs,  costal  cartilages,  or  sternum. 

Differential  diagnosis — In  its  earliest  stage,  tuberculosis 
of  the  breast  cannot  be  distinguished  from  chronic  mastitis.  In  the 
stage  prior  to  softening  and  abscess-formation  it  may  closely  resemble 
carcinoma.  The  tuberculous  patient  is,  however,  generally  under  35, 
and  usually  presents  multiple  indurations,  while  a  carcinoma  is  com- 
monly a  single  lump.  The  presence  of  a  central  area  of  softening  in 
the  mass  and  of  reddening  of  the  skin  points  to  tuberculosis,  and  the 
diagnosis  is  confirmed  if  pus  be  withdrawn  by  a  hypodermic  syringe. 
In  very  rare  cases,  tuberculosis  and  carcinoma  may  coexist.  Gumma 
of  the  breast  may  closely  resemble  tuberculosis  {see  p.  29).  The 
diagnosis  between  chronic  abscess  and  simple  cyst  is  made  by  ex- 
ploratory puncture  if  signs  of  pointing  fail  to  give  the  clue.  In  duct 
papilloma,  discharge  from  the  nipple  usually  occurs  at  some  time  or 
other.  Actinomycosis  of  the  breast  can  only  be  differentiated  by 
the  detection  of  the  ray  fungus. 

Prognosis. — Mammary    tuberculosis     has    little    tendency    to 


MAMMARY    ACTINOMYCOSIS 

spontaneous  cure,  and,  if  untreated,  will  probably  lead  to  multiple 
sinuses  persisting  for  years.  The  continued  discharge  may  under- 
mine the  health  and  lead  t<>  lardaceous  disease.  In  the  absence  ot 
othei  tuberculous  Lesions  in  the  body,  the  prognosis  after  removal  of 
the  breast  is  good.  The  subsequent  development  of  tuberculosis  in 
the  other  breast  is  very  rare,  but  20  per  cent,  of  patients  who  have 
suffered  from  mammary  tuberculosis  die  ultimately  of  phthisis. 

Treatment. — If  a  chronic  ahsce>s  is  the  only  si<m  of  disease  in 
the  breast,  it  may  suffice  to  open  it.  to  scrape  it,  and  to  allow  it  to 
heal  from  the  bottom.  But  if.  as  is  usual,  there  are  multiple  foci, 
it  is  wiser  to  amputate  the  breast.  The  axillary  glands,  if  markedly 
enlarged,  should  be  removed  at  the  same  time.  Partial  resection 
of  the  breast  is  justifiable  in  young  women  if  the  disease  is  definitely 
confined  to  certain  lobules. 

No  experience  as  to  the  effects  of  tuberculin  in  mammary  tubercle 
is  yet  available.  Unless  it  becomes  possible  to  make  the  diagnosis 
earlier  than  at  present,  it  seems  unlikely  that  tuberculin  treatment 
will  supersede  operation.  It  is  stated  that  Bier's  treatment  by 
passive  hyperemia  has  given  good  results  (see  p.  18), 

ACTINOMYCOSIS 

Actinomycosis  is  one  of  the  rarest  mammary  diseases.  It  may 
reach  the  breast  primarily  through  a  wound  or  abrasion,  or  secondarily 
by  extension  from  the  lungs  and  pleura,  or  by  metastasis  from  other 
organs.  In  its  early  stage  the  disease  presents  itself  as  one  or  more 
areas  of  local  induration  indistinguishable  from  the  vague  indurations 
of  chronic  mastitis,  or  as  a  definite  rounded  tumour.  The  axillary 
glands  are  usually  unaffected.  Later,  at  various  points  over  the 
indurated  area,  softening  may  be  detected.  The  skin  at  these  points 
becomes  reddened,  glazed,  and  thinned,  and  finally  gives  way.  A 
number  of  discharging  sinuses  are  left,  burrowing  in  various  directions 
through  the  shrunken  breast,  and  exuding  pus  containing  the  charac- 
teristic and  diagnostic  "  iodoform  granules.'"  The  disease  may  spread 
by  metastasis  to  other  regions  of  the  body. 

Treatment. — In  the  early  stage  the  free  administration  of 
potassium  iodide  in  large  doses  is  indicated.  Later,  if  the  disease  is 
primary,  complete  excision  of  the  affected  breast  is  probably  the  best 
treatment.  If  the  disease  is  well  localized  the  affected  part  may  be 
resected. 

GUMMA   OF    THE    BREAST 

In  the  tertiary  stage  of  syphilis,  localized  deposits  of  syphilitic 
granulation  tissue  may  occur  in  the  breast  as  in  most  other  parts  of 
the  body.  Gummata  of  the  breast  are,  however,  not  common.  They 
may  be  single  or  multiple,  and  are  rarely  found  except  in  association 


30  THE   BREAST 

with  active  manifestations  of  the  disease  in  other  regions — a  fact  which 
is  of  great  assistance  in  diagnosis.  A  jrumma  presents  itself  as  a  firm 
and  'vcn  hard  tumour,  fixed  in  the  breast,  painless,  palpable  with 
the  flat  hand,  and  sharply  defined  from  the  surrounding  tissues.  It 
soon  becomes  adherent  to  tli<-  skin  and  to  the  underlying  pectoral 
fascia.  The  adherent  skin  may  present  the  peau  <F orange  appearance. 
Retraction  of  tin-  nipple  may  be  present  if  the  tumour  is  subareolar. 
Up  to  tins  stage  the  di   g  inoxna  depends  chiefly  upon 

the  history,  and  upon  the  presence  of  other  syphilitic  lesions.  Soon, 
however,  the  adherent  skin  over  the  tumour  becomes  thinned  and 
congested,  and  a  central  area  of  softening  appears  in  the  hard  tumour. 
The  skin  now  gives  way  and  a  puriform  discharge  escapes.  The  nicer 
thus  formed  may  present  the  characters  of  a  typical  gummatous  ulcer 
with  a  sloughy  base.  Occasionally  a  massive  slough  is  thrown  off, 
and  the  ulcer  spontaneously  heals.  The  glands  in  the  axilla  do  not, 
as  a  rule,  become  enlarged  unless  secondary  infection  occurs  through 
the  ulcer.  Treatment  is  an  important  means  of  confirming  a  pro- 
visional diagnosis  of  gumma.  In  rare  cases,  diffuse  unilateral  indura- 
tion of  the  breast  has  been  observed  comparatively  early  in  the 
secondary  stage  of  syphilis. 

Treatment. — The  only  treatment  required  is  the  regular  and 
vigorous  administration  of  potassium  iodide,  beginning  with  5  or 
10  gr.  thrice  daily,  and  increasing  the  dose  to  20  or  even  30  gr.  The 
induration  rapidly  and  completely  disappears.  If  the  gumma  is 
ulcerated  a  mild  mercurial  ointment  should  be  applied. 

HEMATOMA  OF  THE  BREAST 
This  condition  is  not  often  seen,  and  is  usually  due  to  a  blow. 
The  rapid  appearance  of  a  traumatic  swelling,  associated  after  a  day  or 
two  with  cutaneous  eechymosis,  and  its  disappearance  within  two  or 
three  weeks,  are  characteristic  points.  The  swelling  may  correspond 
in  outline  to  the  sector-shape  of  a  single  mammary  lobe,  or  of  several 
adjacent  lobes.  Hematoma  may  follow  an  operation  for  the  removal 
of  a  simple  tumour,  unless  the  cavity  left  is  carefully  obliterated. 

Treatment. — The  breast  should  be  strapped,  or  at  least  sup- 
ported in  a  sling,  and  manipulation  must  be  avoided.  In  view  of 
the  fact  that  trauma  is  a  possible  cause  of  malignant  disease,  a  short 
prophylactic  course  of  X-rays  may  be  advisable.  If  a  swelling  remains 
after  the  lapse  of  some  weeks,  an  exploratory  incision  must  be  made. 

ELEPHANTIASIS 

In  tropical  countries,  in  one  case  in  690  of  elephantiasis,  the 
disease  affects  the  breast.  The  breast  becomes  enormously  and 
uniformly  enlarged,  and  the  skin  over  it  thick,  leathery,  and  pitted 


CI  SIS   OF   THE    BREAST  31 

l>v  enlarged   gland   orifices.    The   nipple   may    bang  as   Low   as  the 
umbilicus,  and  may  even  reach  the  pul.es. 

These  changes  arc   preceded   by   attacks  of  acute   Lymphang 
which  lead  to  obliteration  of  many  of  the  Lymphatics  ol  the  breast. 
The  enlargemenl  of  the  organ  and  the-  thickening  of  the  skin  over  it 
are  results  of  lymphatic  obstruction.     The  cutaneous  appearances  arc 
exactly  those  of  the  '"pic-kin"  familial-  in  oases  of  carcinoma. 

Diagnosis.  In  tropical  countries,  confusion  may  arise  between 
elephantiasis  and  malignanl  disease  of  the  breasi .  Bui  in  elephantiasis 
the  breasi  is  very  greatly  enlarged  and  no  lump  is  present  in  it. 

Treatment.  In  early  stages  the  breast  must  be  supported 
by  a  sling.  In  view  of  recent  work  by  Dufougere,  Foulerton,  and 
myself,  which  tends  to  prove  th.it  elephantiasis  depends  upon  a 
chronic  infection  by  the  Staphylococcus  pyogenes  albus,  a  vaccine  of 
this  organism  should  be  tried  to  arrest  the  disease  in  its  earlier  stages. 
But  in  late  cases  amputation  of  the '  breast  is  indicated.  It  is  un- 
rv   to  remove  the  pectoral  muscles  or  to  clear  out  the  axilla. 

I  YSTS   OF    THE    BREAST 

Cysts  of  the  breast  may  be  divided  clinically  into  two  main 
classes — (1)  those  arising  in  connexion  with  solid  neoplasms  (neoplastic 
I,  and  (2)  those  of  obstructive  or  inflammatory  origin  where  no 
new  growth  is  present  (simple  cysts).  It  is  difficult  to  be  sure  that 
a  cyst,  apparently  simple,  is  not  really  neoplastic.  When  a  cyst 
has  been  assigned  to  the  neoplastic  category  the  vital  question  still 
remains  whether  the  solid  tumour  connected  with  it  is  innocent  or 
malignant. 

-rs  of  the  breast  usually  occur  after  the  age  of  40.  They  are 
not  very  common,  forming  less  than  3  per  cent,  of  cases  of  mammary 
tumour  which  come  under  hospital  treatment. 

The  many  varieties  of  cysts  that  occur  in  the  breast  may  be 
classified  as  follows  : — 

1.  Cysts  arising  from  distension  of  the  larger  ducts.     These  cysts 

are  usually  single  and  situated  near  the  nipple, 
i.  Galactocele,  or  milk-cyst, 
ii.  Simple  subareolar  cyst. 

2.  Multiple   cysts   arising   from   distension   of  the   smaller  ducts. 

These  cysts  are  the  result  of  chronic  mastitis.  The  condition 
known  as  general  cystic  disease  of  the  breast  is  simply  an 
exaggerated  form  of  cystic  chronic  mastitis  (Fig.  254,  p.  20). 

3.  Cysts  due  to  the  distension  of  lymphatic  spaces. 

4.  Cysts  arising  in  connexion  with  simple  tumours. 

i.  Cystic  fibro-adenoma. 
ii.  Cystic  duct  papilloma   (Fig.   266). 


32  THE   BREAST 

5.  Cysts  arising  in  connexion  with  malignant  tumours. 

i.  Carcinoma  with  cystic  degeneration,  or  arising  in  the 

wall  of  a  pre-existing  cyst, 
ii.  Cystic  forms  of  sarcoma. 

6.  Parasitic  cysts  due  to  the  echinococcus. 

In  this  section  galactoceles,  simple  subareolar  cysts,  and  hydatid 
cysts  will  be  considered  ;  cysts  of  neoplastic  origin  will  be  dealt  with 
in  the  section  relating  to  the  tumours  with  which  they  are  associated. 

Galactocele 

A  galactocele  is  a  rare  mammary  cyst  containing  milk  in  a  more 
or  less  inspissated  and  altered  condition.  Arising  from  the  obstruction 
of  one  of  the  large  ducts  or  milk  sinuses,  these  cysts  are  formed  during 
lactation,  though  they  may  persist  after  it  has  ceased.  In  rare  cases, 
galactoceles  are  said  to  occur  in  women  who  have  never  been  pregnant, 
but  some  of  these  cases  are  probably  tuberculous  abscesses.  The 
nature  of  the  causative  obstruction  is  not  certainly  known.  Some 
authors  maintain  that  it  arises  from  excessive  proliferation  of  the 
duct  epithelium  ;  and  blows,  injuries,  and  surgical  incisions  near  the 
nipple  have  been  claimed  as  etiological  factors. 

Galactoceles  are  situated  beneath  or  near  the  areola,  and  are,  as 
a  rule,  single,  though  I  have  seen  two  in  the  same  breast.  They  are 
of  moderate  size,  rarely  exceeding  3  in.  in  diameter  ;  but  one  enormous 
example,  recorded  by  Scarpa,  after  two  months'  growth  contained 
10  pints  of  milk.  The  wall  of  the  cyst,  which  in  old  examples  may 
be  of  some  thickness,  is  composed  of  fibrous  tissue  and  lined  by  the 
stretched  and  atrophied  epithelium  of  the  duct.  The  contents  may 
resemble  colostrum,  or  normal  inspissated  milk,  or  may  be  a  butter- 
like material. 

Symptoms  and  signs. — Close  to  the  areola  there  is  present 
a  rounded,  painless,  fluctuating  swelling,  which  on  pressure  exudes  a 
milky  fluid  through  the  nipple.  It  usually  appears  during  the  early 
weeks  of  lactation,  and  may  increase  in  size  during  the  act  of  suckling 
(Astley  Cooper).  In  long-standing  cases  its  contents  become  inspis- 
sated and  its  consistence  doughy. 

Diagnosis. — The  commencement  during  lactation,  and  the  exud- 
ation of  milk  from  the  nipple  if  the  cyst  be  pressed,  usually  render 
diagnosis  easy.  A  galactocele  may,  however,  be  mistaken  for  a  chronic 
tuberculous  abscess,  for  a  simple  subareolar  cyst,  or  for  a  cyst  con- 
nected with  duct  papilloma. 

Treatment. — Unduly  active  treatment  is  to  be  deprecated.  If 
the  cyst  reaches  any  size  the  child  should  be  weaned,  the  cyst  aspi- 
rated, and  pressure  applied  to  the  breast  by  strapping.  If  these 
measures  fail,  the  cyst  is  to  be  incised  radially  from  the  nipple,  and 


MAMMARY    CYSTS  33 

either  completely    removed,   or   packed    and    allowed    to    heal    Erom 
the  bottom. 

Simple  Subareolar  Cyst 

Simple  subareolar  cysl  is  due  to  ( he  obsl  rucl  ion  of  one  of  t  he  large 
ducts  near  the  nipple.  These  cysts  are  usually  Bingle,  contain  clear 
Berous  fluid,  and  seldom  exceed  1  to  H  in.  in  diameter.  They  are 
frequently  associated  with  a  vague  induration  of  the  corresponding 
lobe  of  the  breast.  Fluctuation  is  usually  evident.  Pain,  tenderness 
and  enlargement  of  the  axillary  glands  are  generally  absent.  A  dis- 
charge Erom  the  nipple  is  occasionally  present,  but  if  marked,  and 
especially  if  blood-stained,  it  should  arouse  suspicion  that  the  cyst  is 
associated   with  duet  papilloma. 

Cysts  exactly  resembling  the  subareolar  cysl  may  arise  from  the 
distension  of  ducts  in  the  deeper  parts  of  the  breast  ;  they  are  usually 
associated  with  chronic  mastitis. 

Treatment. — Any  suspicion  of  malignancy  must  lead  to  an 
immediate  exploratory  operation  (see  p.  86).  If  the  cyst  is  certainly 
innocent,  milder  measures  may  be  tried.  The  cyst  may  be  aspirated 
and  the  breast  subsequently  strapped.  A  more  effective  method  is 
to  tap  the  cyst  with  a  hypodermic  needle,  and  to  inject  5  to  10  minims 
of  1  per  cent,  solution  of  protargol,  or  the  same  quantity  of  pure 
phenol.  The  breast  is  subsequently  manipulated  to  ensure  that  the 
fluid  comes  in  contact  with  the  whole  interior  of  the  cyst.  If  these 
measures  fail,  the  cyst  must  be  excised  through  an  incision  radiating 
from  the  nipple  so  as  not  to  divide  any  of  the  ducts.  In  certain  cases, 
Gaillard  Thomas's  operation  (see  p.  40)  may  be  employed. 

Hydatid  Disease  of  the  Breast 

Tliis  condition  is  of  great  rarity.  A  small,  painless,  hard  lump 
forms  in  the  breast,  and  is  discovered  by  accident.  When  it  reaches 
the  size  of  an  egg,  fluctuation  can  usually  be  detected  in  it.  Further 
slow  increase  in  size  during  a  period  of  years  produces  a  prominent 
globular  tumour  as  large  as  an  orange,  moving  with  the  breast,  still 
painless,  and  not  adherent  either  to  skin  or  fascia.  The  nipple  is  not 
retracted,  nor  are  the  axillary  glands  enlarged.  If  nothing  is  done, 
suppuration  may  ultimately  occur,  probably  as  a  result  of  the  death 
of  the  hydatid.  Pain  is  felt  in  the  swelling,  the  skin  becomes  reddened, 
and  the  tumour  itself  is  larger  and  more  prominent.  The  integument 
becomes  thinned  at  one  or  several  points,  and  sinuses  form  through 
which  thin  pus  is  discharged,  containing  daughter-cysts  and  hydatid 
membrane.  In  this  way  the  whole  of  the  hydatid  may  be  discharged, 
and  a  spontaneous  cure  may  result. 

Diagnosis. — The  presence  of  a  globular,  painless,  fluctuating 
,1 


34  THE   BREAST 

single  tumour,  of  slow  growth,  of  considerable  size,  and  presenting  the 
other  characters  already  referred  to,  raises  a  presumption  of  hydatid. 
A  hydatid  cyst  does  not  give  rise  to  discharge  from  the  nipple — a  point 
of  distinction  from  cystic  duct  papilloma.  A  simple  cysl  rarely  attains 
a  size  beyond  that  of  an  egg.  The  diagnosis  can  only  be  made  con- 
clusive by  an  exploratory  puncture.  If  the  fluid  withdrawn  is  free 
from  albumin,  and  more  especially  if  it  contains  booklets,  the  diagnosis 
of  hydatid  is  established. 

Treatment. — The  disease  is  practically  free  from  risk  to  life. 
An  incision  radiating  from  the  nipple  is  made  down  upon  the  cyst, 
which  is  enucleated  entire.  The  cavity  may  be  obliterated  by  suturing 
its  walls  together,  and  the  skin  sewn  up.  Of  course,  if  suppuration 
is  present,  no  attempt  to  secure  primary  union  must  be  made. 

Diagnosis  of  mammary  cysts.  —  Cysts  of  the  breast  are 
often  very  tense,  and  consequently  fluctuation  is  frequently  absent, 
and  diagnosis  from  a  solid  tumour  may  be  impossible,  especially  if 
the  cyst  is  deeply  situated,  without  the  aid  of  an  exploring  needle. 
The  use  of  this  instrument  is  free  from  objection,  and  is  painless  if  a 
little  ethyl  chloride  be  used  to  freeze  the  skin.  Microscopical  examina- 
tion decides  whether  the  fluid  is  milky  as  in  galactocele,  serous  as  in 
duct  papilloma,  purulent  as  in  tuberculous  abscess  or  acute  mammary 
abscess,  containing  booklets  as  in  hydatid  cyst,  or  bloody  as  in  malig- 
nant growth  and  in  duct  papilloma.  Usually  the  microscopical  examina- 
tion is  practically  negative.  If  albumin  is  present  in  the  fluid,  non- 
suppurating  hydatid  cyst  is  of  course  excluded,  and  the  diagnosis 
probably  lies  between  two  common  types  of  cyst — the  simple  cyst 
associated  with  chronic  mastitis,  and  the  papilloma-bearing  cyst.  In 
the  latter  case  there  is  usually  a  history  of  serous  discharge  from  the 
nipple,  often  blood-stained. 

This  brief  summary  fails  to  take  account  of  the  cysts  associated 
with  malignant  tumours,  which,  though  rare,  are  of  great  importance. 
The  question,  "  Is  a  malignant  neoplasm  also  present  ?  "  arises  in 
every  case  of  cyst.  The  size  of  the  cyst  is  of  great  significance  in 
settling  this  question.  Simple  cysts  of  the  breast  jgrely  exceed 
1  to  2  in.  in  diameter.  They  are  usually  situated  near~the  nipple, 
and~db~ngt]Tapidly  increase  in~size.  IFthe  cyst  is  large  and  rapidly 
developed,  a  grave  suspicion  of  malignant  disease  or  of  duct  papilloma 
must  be  entertained,  even  though  after  aspiration  no  induration 
remains  in  the  breast.  I  have  a  vivid  recollection  of  removing  by 
aspiration  15  oz.  of  fluid  from  a  cyst,  leaving  the  breast  apparently 
quite  soft  and  normal.  AYithin  six  months  the  patient  was  dead  from 
a  most  acute  carcinoma,  which  developed  so  rapidly  that  operation 
was  evidently  useless.     The    rare    cases    of    rapidly    growing    cystic 


I  l   MOURS  3.5 

adenoma  are  qo1  numerous  enough  to  impair  the  validity  of  the  rale. 

Moreover,  in  view  of  the  affinity  of  this  tumour  with  sarcoma,  ex< 

uf  the  breasl   is  often  the  beal   treatment.     For  .1  large  cysl   <>f  the 

t,  removal  of  the  whole  organ  is  the  only  procedure  which 
any!  hing  like  absolute  security. 

When  a  cysl    is  excised  a  microscopica]  examination  <>f  tin- 
wall  musl   "ii   do  account   be  omitted  even  when  the  charact 
excised  cysl   appear  to  be  innocent. 

TUMOURS  OF  THE  BREAST 

On  its  clinical  side  the  Bubjecl  of  tumours  of  the  breasl  is  complex 
and  difficult,  while  pathologically  it  is  relatively  simple,  though  its 
literature  is  puzzling  owing  to  a  redundant  nomenclature. 

following  lisl  appears  to  contain  all  tumours  primary  in  the 

t.     It   might   be  lengthened   by  adding  tumours  of  extraneous 

Buch  as  secondary  melanotic  sarcoma,  or  angioma  of  the  skin 

invading  the  breast,  or  by  wrongly  assuming  that  secondary  accidents 

and   degenerations,    such   as   colloid   change   in    carcinoma   or   1 

changes  in   fibro-adenoma,  are  fundamental   characters. 

A.  Innocent  Tumours. 

(a)  Of  epithelial  origin,  wholly  or  mainly. 

1.  Duct  papilloma. 

2.  Pure  adenoma. 

(b)  Of  connective-tissue  origin,  wholly  or  main  1  v. 

1.  Fibro-adenoma. 
-.  Soft  fibro-adenoma. 

•  I.  Fibroma  (probably  a  fibro-adenoma  from  which  epithe- 
lium has  disappeared). 
4.  Lipoma. 
•"».  Myxoma. 

B.  Malignant  Tumours. 

(a)  Of  epithelial  origin. 

Carcinoma. 

i.  Spheroidal-celled,   originating  in  the  acini. 
ii.  Columnar-celled,  originating  in  the  ducts. 

(b)  Of  connective-tissue  origin. 

Sarcoma,  round-,  spindle-,  or  mixed-celled,  or  containing 
cartilage  (chondro-sarcoma)  or  bone. 

Ernest  Shaw  has  well  summarized  the  relations  of  the  mammary 
epithelium  to  tumour  formation.     He  points  out  that  the  epithelium 
in  a  duct  or  acinus  may  grow  (a)  outwards,  away  from  the  In- 
or  (b)  inwards,  into  the  lumen.     In  the  former  case  the  cells  may  in 


36  THE   BREAST 

their  growth  cither  (a)  imitate  the  normal  gland  tissue,  forming  new 
acini  and  ducts,  accompanied  by  supporting  connective  tissue 
(adenoma),  or  (b)  grow  out  in  a  disorderly  manner,  sometimes  pre- 
serving for  a  time  their  tubular  arrangement  (adeno-carcinoma),  but 
later  penetrating  the  basement  membrane  and  then  infiltrating  other 
tissues  (carcinoma  and  duct  carcinoma).  If  the  cells  grow  into  the 
lumen  of  a  duct  they  may  similarly  (a)  form  a  regularly  organized 
simple  papilloma  (duct  papilloma),  or  (b)  form  an  irregular  mass  of 
cells  which  ultimately  breaks  through  the  wall  of  the  duct  and 
infiltrates  the  tissues  beyond  (duct  carcinoma). 

FIBROADENOMA1 

This  simple  tumour  consists  of  an  encapsuled  mass  of  fibrous 
tissue  containing  tubes  or  spaces  lined  by  epithelium.  A  large  majority 
of  the  simple  tumours  of  the  breast  are  fibro-adenomas.  When  the 
term  fibro-adenoma  is  used  alone,  the  ordinary  or  hard  fibro-adenoma 
is  meant.  This  will  be  first  described,  and  afterwards  the  rare  soft 
variety  will  be  considered.  Fibro-adenomas  may  be  single  or  multiple, 
and  may  present  themselves  in  one  breast  or  in  both.  They  are  very 
rare  in  the  male  breast.  The  smallest  examples  are  of  microscopic 
dimensions,  while  the  largest  may  be  3  in.  or  more  in  diameter,  en- 
larging the  breast  and  forming  a  considerable  part  of  its  bulk.  Usually 
they  do  not  exceed  the  size  of  a  hen's  egg.  They  most  commonly 
affect  the  neigh bourhpocl  ot  the  nipple  and  "the  axillary  tail  of  the 
breast.  Their  outline  is  sometimes  obscured  by  a  surrounding  area 
of  coarse  granular  induration  due  to  local  chronic  mastitis,  probably 
caused  by  obstruction  of  some  of  the  ducts  by  the  tumour. 

Etiology. — Nothing  certain  is  known  with  regard  to  the 
causation  of  these  tumours.  Among  100  cases  of  fibro-adenoma 
observed  by  Bryant,  27  were  first  discovered  between  puberty  and 
the  age  of  20  ;  35  between  20  and  30  ;  22  between  30  and  40  ;  13 
between  45  and  50  ;  and  3  after  50.  Forty-six  of  the  patients  were 
unmarried,  37  fruitfully  married,  and  15  married  but  sterile.  In 
reference  to  these  figures,  it  must  be  noted  that  a  small  tumour  in 
the  breast  may  remain  undiscovered  for  years,  and  it  is  probable 
that  nearly  all  fibro-adenomas  arise  between  puberty  and  30  years 
of  age  ;  they  do  not  occur  before  puberty.  They  sometimes  respond 
by  increased  growth,  after  remaining  stationary  for  years,  to  the 
stimulus  of  pregnancy.  In  a  case  of  Erichsen's  a  fibro-adenoma 
the  size  of  a  walnut,  after  persisting  unchanged  for  eighteen  3 
assumed  the  characters  of  a  soft  fibro-adenoma,  and  rapidly  grew  until 
in  six  months  it  weighed  5  lb.  Such  cases  suggest  the  origin  oi 
coma  from  fibro-adenoma,  a  question  which  will  be  again  referred  to. 
1  See  also  Vol.  I.,  pp.  432  el  seq. 


HARD    FIBRO-ADKNOM A  37 

Morbid  anatomy.  Fibro-adenomas  are  always  Burronnded  by 
a  wry  definite  capsule  ol  fibrous  tissue  which  is  bul  loosely  adherent 
to  the  surrounding  breasl  Bubstance.  In  shape  the  smaller  examples 
arc  spheroid  or  ovoid,  while  the  larger  ones  are  mm. re  or  less  lobulated 
(Kg,  260).  On  section  the  capsule  is  seen  as  a  layer  clearly  denned 
from  the  whitish  or  pinkish- white  Bubstance  oi  the  tumour.     Knobbed 

and    foliated     fibrOUS    masses    may 

protrude  Erom  I  be  cu1  surface,  or 
the  tumour  may  he  homogene- 
ous, presenting  a  smooth  section 
marked  by  whorls  and  bands  of 
fibrOUS  tissue,  ill  w  Inch  here  and 
there  a  few  small  stellate  clunks 
are  just  visible  to  the  naked  eye. 

Microscopical  anatomy. 
— Fibro-adcnomas  arise  from  local 
hvpertrophy  of  the  transparent 
til  nous  tissue  surrounding  the  epi- 
thelial tubes  of  the  breast,  called 
by  Warren  the  periductal  tissue, 
which  develops  at  puberty.  The 
epithelium  in  many  cases  of  fibro- 
adenoma appears  to  play  a  purely 

passive    role,    but    sometimes    the       Fig.  260. — A  typical  fibro-adenoma 
acini    exhibit      considerable     pro-  after  enucleation, 

liferativc  activity.  The  micro- 
scopical varieties  of  fibro-adenoma  are  not  clinically  distinguishable. 

Origin  and  development  of  fibro-adenomas. — In  the 
common  form  of  fibro-adenoma,  called  by  American  authors  intra- 
canalicular,  the  growing  fibrous  tissue  around  a  duct  becomes  con- 
voluted and  infolded  into  the  interior  of  the  duct  in  the  form  of 
blunt  rounded  processes,  each  of  which  is  covered  by  atrophic  epithe- 
lium representing  the  stretched  epithelium  of  the  duct.  Secondary 
knobs  and  convolutions  develop  upon  the  ingrowing  processes.  The 
whole  interior  of  the  rounded  tumour,  within  its  fibrous  capsule,  is 
packed  with  these  blunt  polygonal  processes.  If  in  this  stage  the 
tumour  is  cut  into,  the  closely  packed  lobulated  masses  come  apart 
and  protrude  through  the  incision  (Fig.  261,  b).  If  an  empty  paper 
bag,  squeezed  together  by  the  hands  into  a  tight  ball,  be  cut  through 
with  a  knife,  the  appearance  of  a  fibro-adenoma  in  section  is  closely 
simulated.  Such  a  paper  ball  is  structurally  comparable  to  a  fibro- 
adenoma. 

A  microscopical  section  at  this  stage  shows  masses  of  fibrous 
tissue  of  polygonal  outline  separated  by  narrow  epithelial-lined  chinks. 


38 


THE   BREAST 


The  process  resembles  superficially  what  is  seen  in  duct  papilloma, 
but  is  really  entirely  different.  In  a  fibro-adenoma  the  actively 
growing  element  is  fibrous  tissue,  and  the  epithelium  plays  a  merely 
passive  role.  In  duct  papilloma,  on  the  contrary,  the  ingrowing 
papilla?  present  wll-developed  and  actively  growing  epithelium,  and 
the  fibrous  core  of  the  papilla  serves  merely  to  nourish  the  active 
epithelium.  A  lack  of  appreciation  of  this  distinction  has  led  to 
endless  confusion  in  works  upon  diseases  of  the  breast.  Discharge, 
from  the  nipple — characteristic  evidence  of  secretory  activity  of  the 
epithelium  in  duct  papilloma — does  not  occur  in  fibro-adenoma.     The 


Fig.  261  (schematic). — Three  stages  in  the  history  of  the  common  intra  - 
canalicular  fibro-adenoma.  a,  Ingrowth  of  the  fibrous  convolutions 
into  the  duct,  b,  Their  full  development,  c,  Consolidation  of  the 
tumour  by  fusion  of  the  apposed  processes.  The  chink-like  spaces 
so  prominent  in  b  have  almost  disappeared. 

mutual  pressure  of  the  closely  packed  fibrous  ingrowths  in  a  fibro- 
adenoma ultimately  leads  to  the  atrophy  and  destruction  of  the 
thinned  epithelium  which  covers  them.  The  narrow  intervening 
chinks  now  become  bridged  by  newly  organized  fibrous  tissue,  and 
the  lobulated  processes  are  consolidated  into  a  solid  fibrous  tumour 
in  which,  here  and  there,  stellate  spaces  lined  by  unobliterated  epi- 
thelium remain.  In  this  stage  a  transverse  section  appears  to  the 
naked  eye  solid  and  homogeneous  (Fig.  261,  c). 

In  an  old  fibro-adenoma  all  traces  of  epithelium  may  become 
obliterated,  and  the  tumour  is  then  classified  as  a  fibroma.  A  rarer 
variety  of  hard  fibro-adenoma,  called  by  American  authors  the  peri- 
canalicular fibro-adenoma,  which  is  clinically  indistinguishable  from 
the  common  variety,  presents  active  overgrowth  of  the  fibrous  tissue 
surrounding  the  acini  and  small  ducts  of  one  or  more  lobules  of  the 


II  \KI)   FIBRO-  \I)I..\()MA 

ml    vvithoul    bulging  of  fibrous  prominences  into  the  inte 
of  the  affected  epithelial  channels.     The  dncts  and  acini  remain  on- 
distorted,    while    the    fibrous    layer   surrounding   them    undergi 

entric   hypertrophy.     Instead    "I"   irregular,    flattened,    chink-like 

es  lined  by  epithelium,  ti  presents  practically  normal 

epithelial  tubes  surrounded  by  masses  "I  fibrous  tissue  arranged  con- 
centrically to  the  epithelial  tubes.     There  is,    h  tial 
difference   between  the  two   forms  of  fibro-adenoma   jusl    described, 
for  the  same  tumour  may  al  different  points  presenl   the  ch 
»th. 

Symptoms  and  signs.  A  fibro-adenoma  of  the  ordinary  or 
hard  variety  presents  itself  as  a  firm,  elastic,  rounded  lump,  not 
usually  larger  than  an  egg,  palpable  with  the  flat  hand,  and  fri 
ini>vaTiTo"in  the  breast  tissues.  There  is  no  adhesion  to  skin  or  fascia. 
nor  enlargement  of  the  axillary  glands.  Retraction  of  the  nipple  never 
occurs.  The  smaller  examples  are  more  or  less  spherical  in  shape; 
in  the  larger  ones  lobulation  becomes  evident.  As  a  fibro-adenoma 
enlarges,  the  subcutaneous  tissues  over  it  seem  to  undergo  atrophy 
from  stretching,  and  the  tumour  becomes  superficial,  lying  close 
beneath  the  skin,  across  which  enlarged  veins  may  often  be  seen 
coursing.  The  skin  glides  freely  over  the  tumour;  on  stretching  it 
the  lobulation  of  the  tumour  may  become  visually  obvious. 

As  a*  rule,  fibroadenomas  do  not  cause  pain,  except  in  neurotic 

-ons,  or  in  those  who  are  obsessed  bv  the  tear  of  cancer.  Not 
Infrequently,  however,  they  become  tender  during  menstruation. 
In  exceptional  cases,  severe  neuralgic  pain  in  the  breast  may  depend 
up<m  the  presence  of  a  small  fibro-adenoma. 

Differential  diagnosis. — A  tense  cyst  in  which  fluctua- 
tion cannot  be  obtained  closely  simulates  a  fibro-adenoma.  The 
diagnosis  is  especially  difficult  if  the  swelling  is  deep  in  the  breast. 
Though  exploratory  puncture  will  often  settle  the  diagnosis,  it  is  not 
imperative,  since  in  either  case  an  operation  is  usually  necessary. 

Considerable  difficulty  may  arise  when  the  fibro-adenoma  is  em- 
bedded in  an  area  of  indurated  chronic  mastitis.  The  rounded  con- 
tours of  the  tumour  are  obscured,  and  its  mobility  sometimes  seems 
to  be  impaired.  In  such  circumstances  it  may  closely  simulate  a 
carcinoma,  and  an  exploratory  incision  may  be  the  only  means  of 
settling  the  diagnosis. 

The  simulation  of  fibro-adenoma  by  certain  forms  of  carcinoma 
is  dealt  with  at  p.  82.  Here  it  need  only  be  said  that  a  tumour  of 
the  breast,  presenting  the  characters  of  a  fibro-adenoma,  should  be 
regarded  with  grave  suspicion  if  it  first  appears  after  the  age  of  40. 

Treatment. — Fibro-adenomas  in  young  women  under  30,  if 
small    and    not    increasing,    may    be    let    alone    if    the    patient    can 


40  THE   BREAST 

be  kept  under  observation.  But  in  view  of  the  mental  uneasiness 
caused  by  any  lump  in  the  breast,  and  of  the  possibility  of  malignant 
change,  excision  is  the  best  treatment,  and  is  imperative  if  the  patient 
is  approaching  middle  age.  The  tumour,  grasped  firmly  in  the  left 
hand,  is  boldly  cut  down  upon  so  as  to  expose  its  capsule  by  an 
incision  radiating  from  the  nipple.  It  can  then  easily  be  enucleated 
from  its  surroundings.  The  cavity  left  is  washed  out  with  1-1,000 
perchloride  of  mercury  solution  to  destroy  any  mammary  epithelium 
set  free,  and  is  obliterated  by  buried  sutures  approximating  its  sides. 
Unless  this  is  done  a  ha3matoma  is  likely  to  appear. 

Gaillard  Thomas's  method. — This  is  a  convenient  opportunity 
to  describe  the  operation  of  Gaillard  Thomas — a  method  of  removing 
simple  tumours  of  the  breast  which  avoids  a  subsequent  visible  scar. 
The  operation  depends  upon  the  fact  that  the  important  arteries  of 
the  breast  enter  at  the  upper  margin,  while  its  posterior  surface  has 
but  few  vascular  connexions  with  the  retromammary  tissues.  The 
incision  follows  the  sulcus  between  the  breast  and  the  chest  wall, 
along  the  outer  and  the  lower  margin  of  the  breast.  The  edge  of 
the  breast  being  exposed,  the  gland  is  stripped  upwards  from  the 
great  pectoral,  and  is  at  the  same  time  rotated  so  as  to  expose  its 
posterior  surface.  The  tumour  is  removed  by  a  radial  incision  into 
the  posterior  surface  of  the  organ,  or  if  necessary  a  sector  of  the  breast 
may  be  removed.  The  cavity  left  is  obliterated  by  buried  sutures, 
the  breast  turned  down  into  position,  and  the  skin  incision  sutured. 
The  operation,  though  satisfactory  unless  the  tumour  is  high  up  in 
the  breast,  and  justifiable  where  aesthetic  considerations  are  dominant, 
is  not  surgically  desirable,  and  should  never  be  used  unless  the  tumour 
is  quite  certainly  non-malignant.  Such  an  extensive  incision  renders 
a  subsequent  operation  for  carcinoma  on  proper  lines  impossible. 

Soft  Fibro-Adenoma 

The  rare  soft  variety  of  fibro-adenoma  is  distinguished  by  its 
rapid  growth,  soft  or  elastic  consistence,  and  occurrence  comparatively 
late  in  life. 

A  soft  fibro-adenoma  may  originate  from  a  hard  one,  or  may  be 
soft  from  the  beginning.  Erichsen  states  that  these  tumours  are 
commonest  between  the  ages  of  35  and  40.  They  are  rapidly  growing 
but  innocent  tumours  which  may  in  a  few  months  attain  the  size  of 
a  cocoa-nut.  But  even  when  the  soft  fibro-adenoma  attains  a  large 
size  it  remains  mobile  and  painless,  and  does  not  display  any  tendency 
to  adhere  to  the  skin  or  fascia,  or  to  cause  enlargement  of  the  glands. 
If  these  signs  develop  the  tumour  must  be  classified  as  a  sarcoma. 

Soft  adenoma  differs  from  the  hard  variety  in  the  nature  of  its 
stroma,  which  is  not  composed  of  dense  fibrous  tissue  poor  in  nuclei, 


SOFT   FIBRO-ADENOMA 


41 


l.ui  is  richly  cellular.  It  may  be  made  up  of  fusiform  cells,  sometimes 
mixed  with  more  fully  developed  fibrous  tissue  In  other  cases  the 
tissue  resembles  myxomatous  tissue,  presenting  stellate  cells  with 
abundant  mucoid  intercellular  Bubstance.  This  appearance  is  prob- 
ably the   result    of   mucoid  degeneration  of  ordinary  fibrous   I 


Fig.  262. — Soft,  rapidly  growing  fibro-adenoma  of  the  breast 
(so-called  sero-cystic  sarcoma  of  Brodie). 

{Beatson,  Edin.  Med.  Jourit.,  Nov.,  1908.) 

Small  cysts  often  occur  in  soft  fibro-adenomas.  The  embryonic  nature 
of  the  fibrous  stroma  of  these  tumours  indicates  their  close  connexion 
with  the  sarcomas,  and  indeed  they  were  formerly  called  adeno- 
sarcomas. 

The  case  recorded  by  Beatson,  and  represented  in  Fig.  2G2,  is  a 
typical  instance  of  a  large  fibro-adenoma  of  the  soft   variety.     The 


42 


THE   BREAST 


patient  was  aged  50,  and  had  noticed  her  righl  breasl  increasing  in 
size  for  a  period  of  two  years.  Pain  was  almost  absent,  and  her 
health  remained  good.  The  tumour  was  situated  in  the  upper  hemi- 
sphere, so  that  the  stretched-out  and  flattened  nipple  is  Been  upon 
its  under  surface.  'The  superficial  veins  were  large  and  distended. 
The  breast  felt  very  heavy,  but  was  freely  movable  under  the  skin 


mi 

i   .'    I  ■ 


■ 


w 


-j '  ■ 


fJLi 

r  /'  j 


■ 

-      -  -■-  '  - 

- 
- 


Fig.  263. — Microscopic  section  of  the  soft  fibro-adenoma  represented 
in  Fig.  262.     Note  the  cellular  embryonic  character  of  the  stroma. 

(Beatson,    I'd; n.    Med.    lour;)..    Xov.,   1908.) 

and  upon  the  fascia.  The  tumour  was  smooth,  elastic,  and  spherical, 
but  with  some  irregularity  of  shape  and  tendency  to  lobulation.  The 
breast  was  not  tender,  nor  were  the  axillary  glands  enlarged.  The 
mamma  was  removed,  and  the  encapsuled  tumour  weighed  6i  lb. 
It  was  solid,  but  parts  of  it  presented  numerous  cysts,  while  at  other 
parts  the  stroma   had   undergone   mucoid  degeneration.     On  micro- 


CYSTIC    FIBRO-ADENOMA 

Bcopioal  examination  the  Btroma  (see  Fig.  263)  was  highly  cellulai    and 
its  appearance,  aparl  from  bhe  clinical  history,  would    < 

pt   fur  the  Eacl   thai  epithelial  structures  usually  disappear  from 
a  sarcoma  of  t  he  breasl . 

Diagnosis.-  Beatson  points  ou1  bhal  there  are  practically  only 
three  conditions  which  lead  to  the  formation  of  really  large  tumours  of 
the  breast,  i.e.  soft  fibro-adenoma  (often  cystic),  hypertrophy,  and 
Bar  coma.  Hypertrophy  is  bilateral,  while  the  other  conditions  are 
unilateral.  A  sairoma,  if  still  encapsuled,  cannol  lie  distinguished 
from  a  soft  fibro-adenoma.  Only  when  a  sarcoma  begins  to  infilti 
bo  that  the  breasl  becomes  fixed  and  the  skin  involved,  can  the 
diagnosis  be  made. 

Treatment. — Since  soft  fibro-adenoma   is    a    large    tumour  to 
which  the  breast  itself  is  merely  a  small  appendage,  amputation  of 
the  whole  breast  is  usually  preferable  to  enucleation.     The  pecto] 
need  not  be  removed,  nor  the  axilla  opened. 

(  'vstic  Fibro-Adenoma 

Most  large  soft  libro-adenomas  contain  cysts.  If  these  are  of  any 
siz.e  the  tumour  is  called  a  cystic  fibro-adenoma.  A  cystic  fibro- 
adenoma may  be  produced  from  fibro-adenoma  by  the  collection  of 
fluid  in  the  epithelial-lined  spaces  and  chinks  which  represent  the 
distorted  original  duct.  This  must  obviously  take  place  before  the 
Btage  of  consolidation  has  begun.  When  the  cystic  tumour  is  cut 
into,  fluid  escapes  and  blunt  foliated  or  lobulated  masses  are  seen 
projecting  into  the  interior  of  the  cyst.  Such  a  tumour  must  be 
clearly  distinguished  from  cystic  duct  papilloma.  Another  form  of 
cystic  fibro-adenoma  is  due  to  partial  or  complete  mucoid  degeneration 
and  liquefaction  of  the  fibrous  substance  of  the  original  tumour. 

A  perfect  tangle  of  nomenclature  has  grown  up  around  this 
form  of  tumour.  Owing  to  the  large  size  it  rapidly  reaches,  and 
the  cellular  character  of  its  stroma,  it  was  formerly  considered  to  be 
a  sarcoma,  and  Brodie  applied  to  it  the  name  sero-cystic  sarcoma. 
Johannes  Miiller  called  it  cysto-sarcoma.  French  authors  called  it 
a  cystadenoma,  a  correct  term,  but  one  which  has  led  to  confusion 
between  this  form  of  tumour  and  the  cystic  duct  papilloma  (papil- 
lary cystadenoma),  an  absolutely  different  condition.  For  this  reason 
the  term  cystadenoma  should  be  deleted  from  the  nomenclature  of 
breast  tumours.  Other  names  which  have  been  applied  to  the  cystic 
fibro-adenoma  are  adenocele,  cystoid  glandular  tumour,  and  cystic 
fibroma.  These  obsolete  terms  are  recorded,  not  to  burden  the 
student's  memory,  but  as  a  key  to  the  literature  of  the  subject. 

Clinical  features. — The  characters  of  cystic  fibro-adenoma 
are  those  of  the  soft  fibro-adenoma  from  which  it  originates,  except 


44 


THE   BREAST 


that  areas  of  definite  fluctuation,   corresponding  to  the  cysts,   may 
sometimes  be  felt. 

Diagnosis. — A  large  tumour  of   the  breast  presenting  fluctuat 
ing  areas  may  be  a  cystic  fibro-adenoma,  a  cystic  duct  papilloma, 
or  a  cystic   sarcoma.     The   history  or  presence  of  serous  discharge 
from  the   nipple   distinguishes  duct  papilloma,   while   signs   of  infil- 
tration will  lead  to  the  diagnosis  of  sarcoma. 

Treatment.  —  The    treatment    is    that    of   soft    fibro-adenoma, 

and  the  prognosis  is  good. 

Fungating  Cystic  Fibro- 
adenoma (Fuxgatixg 
Cystadenoma) 

In  very  rare  cases  of  cystic 
fibro-adenoma  the  skin  over  the 
cystic  portion  of  the  tumour 
becomes  thinned  and  gives  way. 
Serous  fluid  escapes,  and  blunt 
lobulated  and  foliated  masses  of 
fibro-adenomatous  tissue  project 
through  the  opening  (see  Fig. 
264).  Septic  and  inflammatory 
changes  may  occur  in  the  pro- 
truding mass,  which  becomes 
swollen  and  congested,  and 
bleeds  readily.  In  such  cir- 
cumstances the  simulation  of  a 
fun  gating  sarcoma  is  very  close, 
though  the  tumour  is  really 
innocent.  In  these  days  of 
early  treatment  of  breast  tu- 
mours this  condition  is  rarely 
seen. 

Diagnosis. — A  wedge  of 
the  protruding  mass,  £  in.  in 
depth,  should  be  removed  for  microscopical  examination.  No  anaes- 
thetic will  be  necessary. 

Treatment  is  that  of  soft  fibro-adenoma. 

PURE     ADENOMA1 

In  a  pure  adenoma  the  tumour  is  almost  entirely  composed  of 
epithelial  tubes   more   or  less   closely   simulating  normal   acini,   and 
separated    by   a    minimal   amount   of    supporting    fibrous    tissue,   in 
1  See  also  Vol.  I.,  p.  431. 


Fig.  264. — Fungating  cystic  adenoma 
of  the  breast.  The  edges  of  the 
skin  are  rolled  back,  not  thinned 
and  infiltrated  as  in  sarcoma, 
and  a  mass  of  fibro-adenomatous 
tissue  is  protruding. 

(From  a  sptcimen  in  the  Middlesex  Hospital 
Museum.) 


M  VMMAKY    ADENOMA 


which,  affording  to  Ernest  Shaw,  no  fat  is  present.  Owing  to  the 
absence  of  fat,  the  lobular  arrangement,  so  obvious  is  the  normal 
breast,  is  obscured.  Some  of  the  gland  tubes  may  be  dilated  into 
microscopic  cysts,  or  may  form  irregular  spaces  encroached  upon 
by   convolutions    of    the    epithelium.     Regularly    formed    duel 


Fig.  265. — Pure  adenoma  of  the  breast  in  a  young  girl. 

(From  a  case  under  the  writer's  care  at  the  Bolingbroke  Hcsjrital.) 

absent.  The  epithelium,  though  apparently  so  active,  is  everywhere 
confined  within  a  basement  membrane. 

Simple  adenoma  is  one  of  the  rarest  of  breast  tumours,  so  that 
in  a  large  experience  it  may  be  observed  not  at  all,  or  once  only.  It 
occurs  at  any  age  between  puberty  and  the  menopause.  The  case 
which  is  represented  in  Fig.  265  was  observed  by  me  in  a  young  girl 
of  16. 

Clinically,  simple  adenoma  resembles  a  soft  fibro-adenoma,  though 


46 


THE   BREAST 


it  does  not  seem  to  reach  such  a  size.  It  does  not  adhere  to 
the  skin  or  fascia,  but  appears  fixed  in  the  breast.  Enlarged  veins 
may  be  seen  ionising  over  it.  In  my  own  case,  referred  to  on 
p.  45,  the  tumour  appeared  to  constitute  the  whole  breast,  and  but 
for  its  unilateral  character  a  diagnosis  of  hypertrophy  would  have 
suggested  itself. 

Treatment.  —  Enucleation  should  be  attempted  unless  the 
tumour  is  very  large.  In  that  case,  amputation  of  the  breast  may 
be  necessary. 

DUCT    PAPILLOMA    OF    THE    BREAST    (PAPILLARY    CYST- 
ADENOMA,    PROLIFEROUS   CYSTS)1 

This  is  a  condition  in  which  papillomatous  elevations  arise  from 
the  lining  epithelium  of  the  ducts.     Serous  discharge  and  often  bleed- 
ing occur  from  the  papillomatous  masses.     Thus  the  characteristic 
but    not   invariable  feature  of  the   disease   is   a   blood-stained   serous 
__  discharge  from  the  nipple. 

Duct  obstruction  and 
consequent  distension  with 
serous  discharge  frequently 
occur,  and  produce  the  cysts 
characteristic  of  certain  forms 
of  the  disease.  Duct  papil- 
loma is  not  malignant,  but 
in  the  course  of  years  fre- 
quently passes  into  duct 
carcinoma. 

Etiology. — Duct  papil- 
loma appears  to  be  unknown 
before  puberty,  and  to  be 
most  frequent  towards  the 
end  of  active  sexual  life.  It 
may,  however,  occur  in  old 
age,  and  has  been  recorded 
in  the  male  breast.  It  occurs 
equally  in  the  married  and 
the  unmarried. 

Morbid    anatomy. — 


Fig.  266.- 


-Cystic  duct  papilloma  of 
the  breast. 


(From  ii  specimen  removed  by  tin  writer,  and  pre- 
served in  the  Middlesex  Hospital  Museum.) 


Since    the   larger  ducts  con- 
verge  upon  the  nipple,  it   is 
beneath   or  near  the   nipple  that   clinically  appreciable  duct  papil- 
lomas are  most  often  found.     All  the  ducts  may  be  affected,  but  very 
often  the  disease  is  confined  to  one  or  several  of  the  mammary  lobes. 
1  See  also  Vol.  I.,  p.  \X). 


DUCT    PAPILLOMA 


17 


The    acinous   Lobules  of  the  afEected    lobe  or   Lobes,   if   their-   duets 
are  obstructed,  develop  chronic  mastitisj  so  thai   the  affected  lobe  is 
sometimes  mapped  out  as  a  Bector-shaped  area  of  granuh  c  induration 
even  before  the  papillomas  in  its  ducts  have  given   rise  to  a  tumour. 
The  papillomas  are  soft    in  consistence  and  vary  greatly  in  appear- 
ance.    They  may  be    broad-based  and  short,  or  attached  inside  the 
duet  by  a  constricted  narrow  base,  and  giving  off  elongated  proi 
They  may  I"1  closely  Bel  within  the  duct,  or  sparsely  distributed  over 
it-  surface.     They   may  be   minute   and  impalpable,  or  of  consider 
able    Bize.     The    amount    <>f    fluid   secreted    appears   to    vary    con- 
siderably.    Thus    in  some    cases    the    duct    is    distended    merely  by 
the    growth    of    the 
papillomas,  and  the 
tumour  is  practically 
a  solid  one.    In  other 
one    or    more 
large,  freely  fluctuat- 
ing Cysts  make,  their 
appearance,      each 
containing  only  one 
or     two    papillomas 
(Fig.      2G6).        The 
healthy  lobes  of  the 
breast    then    appear 
merely    as    a    small 
appendage  to   these 

cysts.  The  fluid  in  the  cysts,  or  exuding  from  the  nipple,  is  often 
clear  and  straw-coloured  without  cellular  elements.  If  haemorrhage 
occurs  the  fluid  takes  on  a  shade  of  red.  In  the  cysts  it  exhibits 
similar  gradations,  and  in  the  older  cysts  it  may  assume  a  brownish 
opalescent  appearance  which  is  associated  with  the  presence  of 
cholesterin. 

Microscopical  appearances. — The  ducts  of  the  breast  are 
lined  with  a  single  layer  of  columnar  epithelium.  As  might  be 
expected,  therefore,  duct  papillomas  are  composed  of  vascular  branch- 
ing cores  of  fibrous  tissue  covered  with  epithelium  of  the  columnar 
type  (Fig.  268). 

Clinical  features. — Duct  papilloma  is  usually  painless.  Pain 
may.  however,  occur  upon  the  sudden  cessation  of  serous  dis- 
charge owing  to  the  distension  of  the  ducts  by  retained  secretion. 
Ir  may  be  felt  at  menstruation  and  at  no  other  time.  The  patient's 
attention  is  attracted  either  by  intermittent  discharge,  which  may  be 
redder  and  more  profuse  during  menstruation,  or  by  the  discovery 
of  a  tumour.     The   evolution  of  the  disease  is  very  slow,   and  the 


Fig.  267. 


— Section  through  a  cystic  duct 
papilloma. 

(Sr.    Thomas's  Hospital  Museum.) 


THE   BREAST 


discharge  or  tumour  may  be  present  for  ten  or  more  years  before 
advice  is  sought.  Suppuration  of  a  duct  papilloma,  with  protrusion 
of  the  growths  through  an  orifice  formed  by  the  bursting  of  the 
abscess,  has  been  recorded. 

In  all  stages  the  tumour  or  tumours  are  freely  movable  in  the 
breast,  under  the  skin  and  upon  the  fascia.  The  axillary  glands, 
though  from  irritation  they  may  become  easily  palpable,  are  neither 
hard  nor  definitely  enlarged.  The  nipple  is  not  retracted  nor  is  the 
breast    shrunken.      But    it    is    evident    that    the    physical    signs    of 

duct  papilloma  will  vary 
very  greatly  with  the 
number  of  lobes  affected, 
with  the  size  of  the  papil- 
lomas, with  their  degree 
of  secretory  power,  and 
with  the  presence  or  ab- 
sence   of    obstruction    of 


4^0 


One 
small  segment  of  the 
breast,  corresponding  to 
the  particular  orifice  upon 

the  nipple  from  which 
Fig.  268.-Typical  duct  papilloma     Its  nar-        h&    discl  {  is 

row   base   of   attachment   to    the    duct 

wall  is  seen  upon  the  right  of  the  figure,  vaguely  indurated  and 
It  presents  a  delicate  branching  frame-  granular,  while  the  rest 
work  of  fibrous  tissue,  covered  with  a  Df  the  breast  is  soft  and 
single  layer  of  columnar  epithelium.  normal-  Careful  observa- 
Note  the  absence  of  any  sign  of  epithe-        .  ,  ,       ,. 

lial  infiltration  at  the  base  of  the  tlon  sll0ws  that  *he  dlf" 
papilla.      x   10.  charge  comes   exclusively 

from  the  particular  orifice 
upon  the  nipple  which  corresponds  to  the  affected  lobe,  and  from 
none  of  the  other  orifices.  Pressure  upon  the  affected  lobe  increases 
the  discharge,  while  pressure  upon  the  non-indurated  parts  of  the 
breast  is  found  to  have  no  effect.  The  papilloma  itself  is  too 
small  to  be  palpable. 

Later  stage,  tumour  palpable. — The  papilloma  has  now  become 
palpable  as  a  small  firm  tumour  situated  beneath  or  near  the  nipple. 
In  some  cases  the  papillomas  may  attain  a  considerable  size  and 
may  form  a  solid  tumour,  perhaps  an   inch   in   diameter.     But   the 


IH'CT  PAPILLOMA  i  i 

nipple  is  n<>t  retracted,  nor  is  the  Lump  fixed  in  the  breast.  The 
other  signs  arc  unaltered. 

Cystic  duct  papilloma.— If  a  duct  is  blocked  by  the  growth, 
serous    discharge    censes.     If    the    papillomas    possess    considerable 

secretory    power,    the    retained    Becreti listends   the   duct    behind 

the  obstruction.  One  or  more  cysts  of  considerable  size  are  thus 
produced,  to  which  the  remainder  <>f  the  In-east  becomes  a  mere 
appendage.  A  large  fluctuating  swelling  is  present,  perhaps  I  in. 
or  more  in  diameter.  The  solid  papillomas  which  it  contains  cannol 
now  be  fdt,  and  the  history  of  sanious  discharge  alone  gives  the 
clue  to  the  diagnosis.  Retraction  of  the  nipple  and  adhesion  to 
skin  and   fascia   remain  absent. 

Fungating  duct  papilloma  {Jungating  papillary  cystadenoma). 
— In  tare  cases  the  skin  over  a  duct  papilloma  may  undergo  a  kind 
of  pressure  atrophy,  and  may  give  way,  allowing  the  protrusion  of 
the  papillomatous  masses.  The  same  result  may  follow  suppuration 
of  a  duct  papilloma..  Constricted  by  the  margins  of  the  skin  opening, 
the  protruding  mass  becomes  congested  and  hemorrhagic,  and  closely 
resembles  a  Elongating  sarcoma.  It  also  simulates  a  {ungating  cystic 
adenoma.  Malignancy  may  be  excluded  by  the  absence  of  fixation 
and  gland  enlargement.  Microscopic  examination  of  a  portion  of 
the  fungating  mass  may  decide  its  nature. 

Treatment  of  duct  papilloma. — The  knowledge  that  a 
duct  papilloma  often  becomes  malignant  should  exert  more  influence 
upon  its  treatment.  Duct  papilloma  is  often  a  very  circumscribed 
disease,  affecting  perhaps  only  one  lobe  of  the  breast.  In  these  cir- 
cumstances mere  excision  of  the  affected  lobe  is  very  tempting ;  but 
this  policy  is  of  doubtful  wisdom.  Since  the  eye  is  incompetent  to 
map  out  the  exact  limits  of  the  disease,  and  since  early  papillomas 
may  be  present  in  other  ducts,  it  is  much  safer,  in  view  of  possible 
malignant  degeneration,  to  excise  the  whole  breast,  even  for  early 
and  limited  duct  papilloma.  In  young  women,  however,  it  may  be 
justifiable  to  resect  the  affected  lobe  or  lobes,  leaving  the  remainder 
of  the  brea.st. 

The  axillary  glands  need  not  be  removed.  But  the  specimen 
should  be  carefully  examined  for  carcinomatous  change,  and  if  this 
is  found  or  suspected  the  axilla  must  be  cleared  out  at  a  subsequent 
operation. 

LIPOMA   AND    MYXOMA 

Most  so-called  lipomas  of  the  breast  are  really  paramammary  lipomas 
occurring  in  contact   with  the  breast,  but  not  forming  part  of  it. 

Myxoma  of  the  breast  is  merely  a  pathological  curiosity.  It  forms 
an  encapsuled  tumour  resembling  a  fibro-adenoma. 


5o  THE    BREAST 

CARCINOMA    OF    THE    BREAST1 
Etiology. — A   carcinoma    of    the    breast    originates   when    the 
mammary  epithelium,  which  is  normally  confined  within  its  basement 
membrane,  escapes  into  the  tissue  spaces  of  the  breast,  and  continues 
to  proliferate  therein. 

In  females  the  breast  comes  second  only  to  the  uterus  as  a  seat 
of  election  for  malignant  disease  ;  one  case  of  malignant  disease  in 
every  three  affects  the  breast.  On  the  contrary,  only  one  case  in 
every  hundred  of  cancer  in  males  is  of  mammary  origin.  The  com- 
monest sites  of  growth  are  in  the  upper  and  outer  quadrant  or  beneath 
the  nipple.  Though  no  portion  of  the  breast  is  exempt,  the  lower 
and  inner  quadrant  is  the  part  most  rarely  affected.  In  exceptional 
cases  the  growth  begins  in  an  outlying  lobule  situated  beyond  the 
visible  limits  of  the  breast.  Campiche  and  Lazarus-Barlow  find  that 
the  point  of  origin  may  be  expressed  in  percentages  as  follows  : — 

Beneath  nipple 2  .  .      12*2 

In  nipple  .  .  .        7"6 

Upper  and  outer  quadrant       44'9 


Upper  and  inner  quadrant        16-7 
Lower  and  outer        ,,  .      12-4 

Lower  and  inner         ,,  .        6*2 


The  proportion  of  married  persons  in  the  general  female  popula- 
tion above  the  age  of  25  is  about  three  out  of  four,  and  three  out  of 
four  cancers  of  the  breast  are  seen  in  married  women.  Thus  the 
liability  of  married  and  unmarried  women  to  cancer  is  about  the 
same.  Though  a  few  striking  family  histories  have  been  adduced, 
the  influence  of  heredity  in  this  and  in  other  forms  of  cancer  is 
unproven.  Failure  or  inability  to  suckle  at  the  breast,  blows  and 
injuries,  a  family  history  of  tubercle,  and  a  brunette  complexion, 
have  each  been  alleged  as  predisposing  causes.  A  history  of  injury 
is  present  in  about  10  per  cent,  of  cases  of  carcinoma,  but  a  relation 
of  cause  and  effect  has  never  been  proved. 

Age-incidence. — Carcinoma  of  the  breast  is  unknown  before 
puberty,  and  very  rare  before  35.  Most  commonly  it  begins  in  the 
years  immediately  following  the  menopause.  It  remains  frequent  up 
to  the  end  of  life,  in  proportion  to  the  reduced  number  of  persons 
living  at  the  more  advanced  ages. 

Chronic  mastitis  as  a  precursor  of  cancer. — The  most  impor- 
tant factor  in  the  production  of  breast  cancer  appears  to  be  chronic 
mastitis.  Taking  first  the  clinical  evidence,  Bryant  found  that  out 
of  360  cases  of  cancer,  mastitis  had  occurred  at  some  antecedent  period 
in  80.  Gross  found  similar  evidence  in  71  of  365  cases  of  cancer. 
Sheild  found  evidence  of  past  inflammatory  trouble  in  only  10  per 
cent,  of  the  St.  George's  Hospital  cases,  but  he  justly  points  out  that 

1  See  also  Vol.  I.,  pp.  561,  572. 

2  This  table  probably  underestimates  the  frequency  of  growths  beneath  the 
nipple. 


MAMMARY  CARCINOMA:    ETIOLOGY  51 

a  focus  of  chronic  mastitis  much  too  small  to  be  clinically  appre 
oiable  may  yet  form  an  adequate  nidus  for  a  carcinoma.     The  clinical 
statistics,  then,  amount    only    to    this    thai    there    is    evidence   of 
past  chronic   mastitis  in  a  large  minority  of  cases   of  breasl  cancer. 

The  pathological  evidence,  however,  in  favour  <>f  chronic  mastitis 
as  a  cause  is  very  strong.  Beadles,  from  the  examination  of  the 
non-carcinomatous  portions  of  100  cancerous  breasts  al  the  Brompton 
Cancer  Hospital,  found  without  exception  in  each  of  these  breasts 
such  abnormal  changes  as  undue  proliferation  of  the  acini  and  of  the 
stroma,  and  cysts  were  of  common  occurrence.  It  must,  however, 
l>e  remarked  thai  Lenthal  Cheatle  lias  found  similar  changes  post 
mortem  in  apparently  healthy  breasts.  F.  T.  Paul,  as  the  result  of 
prolonged  observations,  recorded  in  1901  his  belief  that  microscopical 
evidence  of  mastitis  is  present  in  nearly  every  breast  affected  with 
carcinoma.  Later,  Victor  Bonney  found  traces  of  chronic  mastitis 
in  all  the  mamma?  removed  for  early  carcinoma  which  he  had  the 
opportunity  of  examining.  Thus,  pathological  investigation  shows 
chronic  mastitis  to  be  an  almost  universal  precursor  of  carcinoma. 

Fibroadenoma  and  carcinoma — General  opinion  favours  the 
view  that  there  is  no  connexion  between  fibro-adenoma  and  car- 
cinoma. At  first  sight  nothing  could  appear  more  innocent  than  a 
fibro-adenoma  of  the  breast,  persisting  possibly  for  years  without 
notable  increase  in  size,  and  securely  walled  off  from  the  normal 
tissues  by  its  strong  fibroua-capstrle.  Yet,  in  my  opinion,  there  can 
be  no  reasonable  doubt  that  in  a  small  proportion  of  cases  malig- 
nant tumours  may  arise  in  or  in  connexion  wdth  these  innocent  neo- 
plasms. Fibro-adenomas  are  often  enveloped  in  an  area  of  breast 
tissue  exhibiting  chronic  mastitis  which  certainly  may  lead  to  cancer. 
It  seems,  then,  probable  that  the  irritative  effect  of  a  fibro-adenoma 
may  be  an  important  factor  in  inducing  cancer  in  the  surrounding 
breast  tissue.  This  view  is  confirmed  by  the  fact  that  the  seat 
of  election  for  breast  cancer — the  upper  and  outer  quadrant,  including 
the  axillary  tail — is   also  the  seat  of  election  for  fibro-adenoma. 

Is  it  possible,  apart  from  the  irritative  effect  of  a  fibro-adenoma 
upon  the  surrounding  tissues,  that  the  tumour  itself  may  undergo 
a  carcinomatous  degeneration  ?  On  various  occasions  I  have  observed 
in  microscopical  sections  of  breast  cancer  an  intimate  admixture  of 
carcinomatous  and  fibro-adenomatous  tissues,  so  that  the  histological 
appearances  of  these  diverse  tumours  should  be  seen  together  on  the 
same  field  of  the  microscope.  Such  observations,  though  suggestive, 
are  not  conclusive.  There  is,  however,  in  the  museum  of  St.  Bartho- 
lomew's Hospital  (3159c)  an  encapsuled  acinous  fibro-adenoma  con- 
taining a  central  opaque  area  of  spheroidal-celled  carcinoma  which 
is  infiltrating  the  substance  of  the  surrounding  fibro-adenoma.     This 


■-"    «<?«V*Ti>  ■--.£•*'-"---.'••••".''— vti*  -         noma. 

.^/.v"*''    lrf$f!§&£<*l^*rf7       *f*,       nety- 

^^   x>^^^v?:^;^&  i     4?&£    the  at 


52  THE   BREAST 

specimen  is,  so  far  as  I  know,  unique,  but  there  seems  no  doubt 
that  it  illustrates  the  possibility  of  the  actual  transformation  of  a 
simple   fibro-adenoma  into  a  malignant  tumour. 

Duct  papilloma  and  malignant  disease. — It  is  generally 
admitted  that  duct  papilloma  may  give  rise  to  duct  carcinoma.  The 
epithelium  at  the  base  of  the  papilloma  may  infiltrate  the  subjacent 
tissues ;  or  the  papilloma  itself,  by  its  continued  growth,  may  erode 
the  opposite  wall  of  the  duct  and  attack  the  tissues  beyond,  where 
its  prominences  lose  their  regular  structure  and  infiltrate  the  tissues 
in  an  irregular  and  malignant  way  (see  Fig.  282,  p.  85). 

Histological    varieties    of    breast    cancer. — Carcinoma 

of     the    breast    presents 
itself  histologically  under 
.'■m^4*4»    J'^'w  two     forms,      spheroidal- 

celled       carcinoma      and 
columnar  -  celled        carci- 
••*>TT  -  ^'-•^'>.-:/':.:.v^';  noma.     The    former    va- 

-by    far    the    more 

lent  —  originates     in 

****?■  .^^^^r^^^^-^Si^r  '•     lid£*    the  acini,  the  latter  in  the 

ducts  of  the  breast.   Some 

growths      present      both 

varieties    of     epithelium. 

%r  ^  Tumours     originating    in 

V*r*2> '*&*& /*^%v'       the  nipple  have  received 

n     ^^^x^^^V^v    X&&*       ''  separate  consideration. 

^Ngjt*,  ".     ^^  '*8f.\  '''  '  Accounts    of   the  his- 

>4-''    f-'~  tology       of       spheroidal- 

celled  carcinoma  have  in 
Fig.  269.-Rapidly  growing  (medullary)  car-      ^  been    unneces. 

cinoma  of  the  breast,  presenting  large  r 

masses  of  epithelial  cells  with  a  mini-  sanly  complicated  because 
mum  of  supporting  fibrous  stroma,  accidental  or  unimportant 
x  90.  variations    in    the    char- 

acter of  the  growth  have 
been  unduly  emphasized.  The  very  diverse  appearances  met  with 
seem  to  depend  mainly  upon  three  variable,  factors- — (a)  the  rate  of 
multiplication  of  the  epithelium  ;  (b)  the  activity  of  stroma  formation, 
i.e.  the  vigour  of  the  reactive  or  defensive  processes  ;  (c)  the  degree 
of  cohesion  between  the  cancer  cells.      (Contrast  Plates  83  and  84.) 

Pathological  basis  of  the  clinical  classification  of 
breast  cancers.  —  The  three  clinical  varieties  of  cancer  of  the 
breast  are  medullary  cancer,  scirrhus   and  atrophic  scirrhus. 

If  the  epithelium  proliferates  very  rapidly,  a  soft,  bulky  tumour 
is  produced,  rich  in    epithelium,  and  called  a    medullary  carcinoma 


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(Kg.  269).  It',  on  the  other  band,  the  proliferative  power  "f  the  epi- 
thelium is  low,  while  tin-  fibrotic  processes  are  active,  the  "atrophic 
Bcirrhus"  of  old  age  results.  If  these  two  opposing  pre* 
balanced,  a  bard  tumour  of  nol  inconsiderable  size,  the  ordinary 
acirrhus,  ia  produced.  The  name  scirrhus  is  often  reserved  for  those 
carcinomaa  where  the  epithelium  has  losl  its  tubular  arrangemenl 
{Vvi.  -Tii)-  If  the  epithelium  possessea  sufficient  power  <>f  coh 
to  retain  in  some  degree  its  arrangemenl  in  eland  tubes,  the  aame 
acinous  carcinoma  or  adenocarcinoma  ia  applicable  (Fig.  271). 

It  is  important  to  recognize  that  all  gradations  occur  between 
the  forms  of  carcinoma  which  have  just  been  named,  and.  moreover, 
that  these  gradationa  may 
occur  in  the  same  tu- 
mour. Thus,  .me  pari 
of  a  tumour  may  present 
a  medullary  appearance, 
while  an  older  part  shows 
a  densely  fibroid  growth 
containing  few  epithelial 
cells.  It  must  be  remem- 
bered that  a  mass  of 
cancer  cells  becomes  in- 
creasingly fibrotic  with 
age.  But  it  is  clinically 
convenient  to  classify  the 
tumour  according  to  its 
size  and  hardness,  as  me- 
dullary cancer,  scirrhus, 
and  atrophic  scirrhus. 

Diffuse  carci- 
noma of  the  breast. 
— Cancer  of  the  breast 
usually  begins  in  one 
small  district  of  the 
breast,  if  not  at  one  mi- 
croscopic point,  and  is  (correctly  described  as  unicentric  in  origin.) 
Cases  are,  however,  met  with  where  the  whole  breast  or  several  of  its 
lobes  appear  to  undergo  carcinomatous  degeneration  en  masse,  the 
disease  lighting  up  simultaneously  in  every  part  of  an  extensive 
district.  These  cases  may  be  described  as  multicentric  carcinoma, 
diffuse  scirrhus,  or  diffuse  carcinoma.  They  include  the  most 
virulent  forms  of  breast  cancer,  and  the  term  diffuse  carcinoma 
may  perhaps  be  regarded  as  the  pathological  equivalent  of  the 
clinical  term  acute  carcinoma  or  mastitis  carcinomatosa  (see  p.  80). 


■rtfw 


V 


Fig.  270. — Typical  appearance  in  chronic 
fibroid  cancer  of  the  breast.  In  a 
groundwork  of  dense  fibrous  tissue  are 
embedded  single  lines  of  compressed 
and  deformed  cancerous  epithelium. 
The  terminal  cells  of  the  line  are 
usually  triangular  in  shape,    x  160. 


54 


THE   BREAST 


Dissemination  of  Breast  Cancer 

It  is  of  primary  importance  to  know  the  mode  and  channels  by 
which  breast  cancer  spreads  from  the  primary  focus  and  gives  rise 
to  secondary  deposits,  for  in  the  absence  of  this  knowledge  it  is 
impossible  to  devise  a  scientific  operation  for  the  extirpation  of  the 
disease. 

Until  recently  the  subject  of  dissemination  was  enveloped  in  con- 
fusion and  uncertainty.  It  was  believed  that  the  secondary  deposits 
situated  near  the  primary  growth  arose  from  particles  carried  along 

the  lymphatics  by  the 
current  ;  while  more  dis- 
tant deposits,  such  as 
those  in  the  liver,  were 
accounted  for  by  the 
embolic  theory.  According 
to  this  theory,  particles 
of  the  primary  growth 
reach  the  blood  by  way 
of  the  axillary  and  su- 
praclavicular glands,  and 
are  carried  by  the  force 
of  the  circulation  to  re- 
mote districts  where  their 
cells  proliferate  and  pro- 
duce secondary  nodules. 
Although,  in  1889,  Heid- 
enhain  found  lymphatics 
filled  with  cancer  cells  ex- 
tending from  the  breast 
to  the  pectoral  fascia  in 
two-thirds  of  the  cancer- 
ous breasts  he  examined, 
this  important  observa- 
tion remained  isolated, 
and  had  no  effect  upon  the  general  doctrine  of  dissemination.  Stiles, 
whose  work  upon  the  surgical  anatomy  of  the  breast  led  to  such 
great  operative  improvements,  writing  in  1889,  continued  to  share  the 
embolic  view  of  dissemination. 

Although  it  has  been  conclusively  shown,  especially  by  M.  B. 
Schmidt,  that  cancer  cells  often  obtain  access  to  the  blood-stream, 
upon  a  close  examination  the  embolic  theory  presents  many  diffi- 
culties. Stephen  Paget  pointed  out  that,  though  embolism  must 
be  an  impartial  process  to  which  all  the  organs  are    liable,  certain 


Fig.  271.  —  Columnar  -  celled  adeno-carci- 
noma  of  the  breast  originating  in  the 
smaller  ducts.  Note  the  irregular  shape 
of  the  gland-spaces.  At  other  points 
in  the  growth  infiltration  had  occurred, 
and  the  cancer  cells  had  lost  their 
gland-like  arrangement,    x  68. 


MAMMARY  CANCER:    DISSEMINATION  55 

organs  axe  very  prone  and  others  relatively  immune  bo  secondary 
deposits  of  cancer.  Thus,  in  pyaemia,  a  knows  embolic  process,  the 
frequency  of  splenic  to  hepatic  abscess  is  as  two  to  three.  In  bre 
cancer  the  frequency  of  splenic  to  hepatic  metastases  is  only  as  one 
to  fourteen.  Again,  the  distribution  of  the  secondary  deposits  is 
not  the  same,  for  instance,  in  cancer  of  the  Uterus  as  in  cancer  of 
the  stomach,  hut  varies  according  to  the  site  of  the  primary  growth. 
\Vt  embolism  must  he  by  its  nature  an  impartial  process.  In  cancels 
which  affect  the  skeleton  the  secondary  deposits  are  frequent  in 
certain  hones  and  very  rare  in  others,  although  all  the  bones  must 
he  liable  to  embolism.  These  difficulties  have  never  been  convincingly 
met  by  the  advocates  of  the  embolic  theory.  In  most  cases,  cancer 
cells  which  gain  access  to  the  blood-stream  appear  to  undergo  de- 
struction. The  details  of  the  process,  as  seen  in  the  lungs,  have  been 
demonstrated  by  M.  B.  Schmidt.  The  peculiarities  of  metastatic 
distribution,  to  be  further  referred  to,  show  that  blocd  embolism  is. 
a  comparatively  unimportant  factor  in  dissemination. 

PARIETAL    AND    VISCERAL    DISSEMINATION 

The  secondary  deposits  in  breast  cancer  may  be  considered  under 
two  headings — first,  those  in  the  parietes  of  the  thorax,  abdomen, 
and  head,  or  in  the  limbs  ;  second,  the  visceral  deposits  within  the 
thorax,  the  abdomen,  or  the  central  nervous  system. 

Dissemination  in  the  parietes. — In  certain  cases,  widespread 
deposits  are  found  in  the  bones  or  the  subcutaneous  tissues,  while  the 
internal  organs  are  free  from  cancer.  The  escape  of  the  internal 
organs  in  such  cases  is  very  difficult  to  explain  if  the  seeds  of  the 
secondary  deposits  are  distributed  by  the  blood-stream.  Moreover, 
on  the  embolic  hypothesis,  subcutaneous  nodules  might  be  expected 
to  crop  up  at  random  anywhere  upon  the  surface  of  the  body.  This 
is  not  the  case.  The  subcutaneous  nodules  which  are  so  frequently 
seen  in  breast  cancer  ahvays  make  their  earliest  appearance  close 
to  the  primary  growth.  Moreover,  I  have  shown  that  they  spread 
away  from  the  (growth  in  a  centrifugal  manner]  and  occupy  an  area, 
roughly  circular,  which  has  for  its  centre  the  primary  growth.  In 
course  of  time  and  in  exceptional  cases,  this  circle  may  occupy  the 
greater  part  of  the  surface  of  the  body,  and  may  spread  to  the  limbs 
and  head.  But  almost  invariably  the  patient  dies  before  subcutaneous 
deposits  have  made  their  appearance  upon  the  distal  portions  of  the 
limbs — the  situation,  of  all  others,  where  embolic  particles  might  be 
expected  to  lodge.  The  arms  below  the  deltoid  insertion,  and  the 
lower  limbs  below  the  middle  third  of  the  thigh,  appear  invariably 
to  remain  free  from  nodules.  The  distal  portions  of  the  limbs  enjoy 
an  immunitv  from   bone  metastases  as  well   as   from   subcutaneous 


56 


THE   BREAST 


nodules.     The  following  tabic  shows  the  experience  of  the  Middlesex 
Hospital  in  this  respect  for  a  period  of  thirty  years  : — 

Table  siiowinc;  the  Frequency  op  Cancerous  Deposit  or  Spontaneous 
Fracture  in  329  Cases  op  Mammary  Cancer  at  the  Middlesex 
Hospital,  1872-1901. 


Bone 


Bones  lying  wholly  or 
partially  within  the 
area  liable  to  sub- 
cutaneous nodules    . 


Bones  lying  beyond 
the  area  liable  to 
subcutaneous  nod- 
ules .... 


Sternum 

Ribs 

Clavicle  . 

Spine 

Cranial  bones 

Scapula  . 

Femur     . 

Os  innominatum 

Humerus 

Radius    . 

Ulna 

Tibia 

Fibula     . 

Patella    . 

Bones  of  hand 

Bones  of  foot 


No.  of 

cases 


Percentage 
of  total 


30 

28 
5 

12 
9 
1 

14 


91 
8-5 
15 
36 
2-7 
0-3 
42 


2-7 


0-3 

0-3 
0-3 


Owing  to  the  impossibility  of  making  a  complete  routine  examina- 
tion of  the  skeleton,  it  is  probable  that  this  table  is  incomplete,  that 
secondary  deposits  in  the  fiat  bones  especially — bones  which,  owing 
to  their  shape,  are  not  liable  to  fracture  as  the  result  of  secondary 
growth— are  more  frequent  than  the  table  would  indicate.  But 
advanced  cancerous  deposit  in  the  bones  of  the  forearm  and  leg  would 
certainly  give  rise  frequently  to  spontaneous  fracture,  and  would 
thus  attract  the  attention  of  the  pathologist.  The  immunity  of  the 
long  bones  of  the  forearm  and  leg  must,  therefore,  be  a  real,  not  merely 
an  imaginary  one. 

The  table  includes  two  cases  which  form  exceptions  to  the  rule 
just  stated.  In  the  first  case,  owing  to  ankylosis  of  the  knee-joint, 
cancer  had  extended  to  the  tibia  and  patella  by  continuity  from  the 
femur.  In  the  second  case,  certain  of  the  metacarpal  bones  were 
fractured  ;  in  this  case,  therefore,  it  appears  probable  that  cancerous 
embolism  along  the  blood-vessels  was  the  cause  of  the  spontaneous 
fracture.  But  it  is  a  very  striking  fact,  as  indicating  the  inefficiency 
of  blood  embolism  in  the  causation  of  bone  metastasis,  that  only 
one  case  in  thirty  years  showed  bone  deposit  in  the  distal  portions 
of  the  limbs.  Judging  by  the  frequency  of  non-cancerous  embolism 
of  the  extremities,  it  is  in  these  that  bone  deposits,  according  to  the 


MAMMARY   CANCER:    DISSEMINATION  57 

embolic  theory,  should  most  frequently  occur.  It  ia  noteworthy  also 
that  cancerous  deposit  in  the  femur, *with  the  rarest  exceptions,  com- 
mences in  the  upper  third  of  the  bone.    The  intimate  connexion  ol 

the  periosteum  with  the  deep  fascia  in  the  region  of  the  great  tro- 
chanter facilitates  the  invasion  of  the  bone  in  the  trochanteric,  region 
as  soon  as  permeation  has  spread  so  far.  Moreover,  spontaneous 
fracture  of  the  humerus  occurs  most  frequently  at  the  level  of  the 
deltoid  insertion.  As  in  the  femur,  fracture  occurs  most  often  at 
the  point  nearest  the  trunk  at  which  the  bone  is  subcutaneous,  and 
consequently  in  close  relationship  with  the  fascial  lymphatic  plexus. 
Speaking  generally,  the  liability  of  a  bone  to  cancerous  deposit  or 
spontaneous  fracture  increases  with  its  proximity  to  the  site  of  the 
primary  growth.  All  these  peculiarities,  difficult  to  explain  on  the 
embolic  theory,  show  the  working  of  a  slow  centrifugal  process  of 
spread  from  the  primary  focus.  It  may  be  especially  mentioned  that 
spontaneous  fracture  of  the  femur  is  three  times  more  common  upon 
the  side  of  the  primary  growth  in  the  breast  than  upon  the  opposite 
side. 

A  femur  fractured  owing  to  secondary  cancerous  deposit  presents 
a  characteristic  skiagraphic  picture  in  that  the  fracture  is  situated 
just  below  the  great  trochanter,  while  the  trochanter  itself  presents 
an  area  of  rarefaction  owing  to  the  replacement  of  bone  by  soft 
malignant  tissue. 

Perhaps  the  most  extreme  instance  of  secondary  bone  deposits  is  the 
ease  of  which  a  plaster  cast  is  preserved  in  the  museum  of  St.  Thomas's 
Hospital.  The  patient  had  a  cancer  of  the  right  breast.  At  the  time  of 
death  the  skeleton  was  greatly  distorted.  The  sternum  and  ribs  sank  until 
the  former  appeared  to  touch  the  vertebral  column,  the  whole  thorax  being 
flattened  out  transversely.  The  pelvis  exhibited  a  precisely  similar  modi- 
fication. The  right  humerus  and  both  femora  were  fractured.  But  the 
forearms  and  the  legs  preserved  their  normal  shape.  Thus  even  in  this 
extreme  case  no  support  can  be  found  for  the  embolic  theory. 

Taking  centrifugal  spread  in  the  parietes  as  proved,  the  question 
arises,  In  wThat  plane  does  the  growth  spread  ?  On  the  assumption 
that  the  growrth  could  spread  along  the  skin  to  a  considerable  distance, 
many  operators  have  advocated  the  ablation  of  very  large  areas  of  skin. 
My  researches  show  that  invasion  of  the  skin  is  secondary  to  spread 
in  the  plane  of  the  deep  fascia.  The  skin  nodules  are  isolated 
efflorescences  springing  up  from  below,  and  the  (skin  is  not  a  highway 
for  the  spread  of  caneer.J  The  growth  spreads  in  the  plane  of  the 
deep  fascia  because  in  this  layer  is  situated  the  main  parietal  lymph- 
atic plexus,  the  fascial  plexus.  The  results  of  operators  who  remove 
large  areas  of  skin  are  less  satisfactory  than  those  of  surgeons  who 
remove   less   skin  and  a  wider  extent  of   deep  fascia.     In   my  own 


58  THE    BREAST 

series  of  cases,  although  the  skin  removed  is  only  a  circle  of  four 
or  five  inches,  but  four  instances  of  recurrence  in  the  skin  have 
come  to  notice. 

Dissemination  within  the  limits  of  the  breast. — Langhans  was  the 
first  to  notice  that  the  small  lymphatics  of  the  breast  are  invaded 
early  and  widely,  far  beyond  the  infiltrating  edge  of  the  primary 
growth.  Stiles  showed  that  the  breast  is  a  far  more  wide-spreading 
organ  than  it  appears  to  be,  and  that  for  its  complete  removal, 
shown  to  be  imperative  by  Langhans'  observations,  an  extensive 
operation  is  necessary. 

Extension  of  growth  to  the  pectoral  fascia. — Heidenhain,  in  1889, 
showed  that  in  two  cases  out  of  three,  lymphatics  filled  with  cancer 
cells  are  present  upon  the  pectoral  fascia.  In  opposition  to  Langhans, 
he  maintained  that  the  process  is  one  of  continuous  growth  along 
the  vessels,  not  one  of  lymphatic  embolism.  Invasion  of  the  lymph- 
atics of  the  pectoral  fascia  precedes  the  clinical  sign  of  adhesion  of 
the  growth  to  the  fascia. 

Embolism  of  the  axillary  glands. — Embolic  invasion  of  the  axillary 
glands  along  their  afferent  trunks  almost  invariably  occurs  as  soon 
as  the  lymphatics  of  the  pectoral  fascia  have  been  invaded.  In  the 
earliest  stage  a  few  cancer  cells  are  seen  lying  in  the  subcapsular 
lymph  sinus  at  the  point  of  entry  of  the  afferent  lymphatics  (Stiles). 
The  cells  slowly  penetrate  to  the  interior  of  the  gland  by  infiltrating 
its  lymph  spaces,  and  ultimately  reach  the  efferent  lymphatics,  along 
which  they  may  be  swept  to  the  supraclavicular  glands.  At  the 
same  time  they  are  infiltrating  the  capsule  of  the  gland,  which  con- 
sequently loses  its  mobility  upon  the  surrounding  structures. 

The  lymphatic  glands  delay  for  a  long  time  the  further  advance 
of  the  cancer  cells,  and  there  is  evidence  that  they  may  destroy  cancer 
cells  brought  to  them,  and  that  they  only  succumb  to  invasion  after 
a  prolonged  resistance.  It  is  important  to  note  that  widespread 
dissemination  may  occur  in  cases  where,  after  death,  the  axillary 
glands  are  found  to  be  free  from  cancer.  In  fact,  the  route  which 
leads  through  the  axillary  glands  is  only  a  by-way  of  dissemination, 
and  not  the  main  avenue. 

Invasion  of  the  opposite  axillary  glands  and  of  the  opposite  breast. — 
In  a  late  stage  of  breast  cancer,  owing  to  extension  of  permeation  across 
the  middle  line,  enlargement  of  the  opposite  axillary  glands  often 
occurs.  A  little  later,  deposits  of  growth  are  noted  in  the  opposite 
breast.  Only  in  rare  cases  is  such  a  deposit  really  a  second  primary 
growth.  In  a  few  cases  the  inguinal  glands  become  enlarged,  show- 
ing that  permeation  has  extended  below  the  level  of  the  umbilicus 
into  the  region  of  the  main  tributaries  of  the  inguinal  glands. 
Embolic  invasion  of  the  inguinal  glands  then  becomes  a  possibility. 


%Xf  yS'/h              i 

'/i  '<-/'-'  *  '->           1 1 

\  V*  ■;  '■                           ' 

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°I    *•                                                        II 

>                                                             '1 

6o  THE    BREAST 

The  permeation  theory. — Although  the  force  of  the  lymph 
stream  carries  cancer  cells  to  the  axillary  glands,  they  are  there  filtered 
off  and  detained.  If  a  reflux  lymph  stream  carries  them  towards  the 
opposite  breast  they  are  similarly  filtered  off  and  detained,  near  the 
middle  line,  in  the  meshwork  of  fine  vessels  which  forms  the  only 
lymphatic  communication  between  the  opposite  sides  of  the  bedy. 
Thus  the  force  of  the  lymph  stream  is  ineffective  as  a  means  of 
general  dissemination  ;  it  is  effective  only  within  the  limits  of  the 
lymphatic  area  in  which  the  primary  focus  is  situated.  In  whatever 
direction  the  cancer  cells  attempt  to  leave  that  area,  they  find  an 
effective  filter  blocking  the  way.  But  they  do  actually  succeed  in 
leaving  it,  as  the  facts  of  dissemination  show.  An  illustration  will 
make  clear  the  method  by  which  they  overcome  the  obstacles  to  their 
spread  into  other  lymphatic  areas.  Certain  bacteria,  which  cannot 
be  forced  through  a  porcelain  filter,  will  nevertheless,  if  left  in  it  for 
a  few  days,  grow  through  its  pores  and  infect  its  outer  surface.  In 
the  same  way,  cancer  cells  are  able  to  traverse  the  lymphatic  plexuses 
by  actually  growing  along  the  fine  vessels  which  compose  them.  This 
process,  which  I  have  called  -permeation,  is  the  master-proces6  of 
dissemination,  for  no  barriers  exist  to  stop  its  slow  centrifugal  pro- 
gress. Permeation  spreads  in  all  directions  with  approximate  equality, 
independently  of  the  direction  of  the  lymph  stream,  but  keeping  in 
the  plane  of  the  main  lymphatic  plexus  until  the  pressure  within  its 
vessels  forces  the  cancer  cells  up  its  minute  tributaries  to  invade  the 
adjacent  layers.  That  is  to  say,  in  the  case  of  the  breast,  the  deep 
fascia  will  be  extensively  invaded  over  a  circular  area  of  which  the 
primary  growth  is  the  centre,  while  a  smaller  circular  area  of  the  skin 
and  of  the  subjacent  muscles  will  show  permeation  or  nodular  deposits. 

Perilymphatic  fibrosis. — In  view  of  its  importance  it  may 
seem  strange  that  the  process  of  permeation  so  long  eluded  notice.  In 
certain  situations,  such  as  the  pleura,  where  it  is  sometimes  visible 
to  the  naked  eye,  it  had  been  described  under  the  name  lymphangitis 
carcinomatosa,  but  its  importance  remained  unsuspected,  and  it  was 
regarded  as  a  pathological  curiosity.  Large  areas  of  a  tissue  thickly 
sown  with  cancer  nodules  may  be  examined  without  finding  any 
trace  of  permeation.  Such  nodules,  it  was  therefore  argued,  must 
have  resulted  from  embolism ;  and  the  argument  appeared  conclusive 
until  I  detected  the  crucial  fact  that  a  lymphatic  along  which  cancer 
cells  have  pushed  their  way  does  not  persist  unchanged.  The  cancer 
cells  by  their  continued  growth  distend  and  finally  rupture  the 
lymphatic.  An  inflammatory  reaction  is  set  up,  abundant  round- 
celled  infiltration  occurs  round  the  liberated  cylinder  of  cancer  cells, 
the  vitality  of  which  has  been  much  impaired  by  pressure,  and  a 
capsule  of  newly  formed  fibrous  tissue  contracts  upon  and  strangles 


MAMMARY    CANCER:    PERMEATION  61 

the  degenerate  cancer  cells.    Finally,  the  original  lymphatic  is  replaced 

by  a  solid  t  bread  of  fibrous  tissue  in  u  hich  do  oancex  oella  can  be  Been, 
This  process  may  be  called  perilymphatic  fibrosis.  While  it  is  taking 
place,  cancer  cells  forced  along  the  lymphatic  capillaries  may  have 
originated  nodular  and  apparently  isolated  deposits  in  the  adjoinii 

layers. 

The  tendency  of  a  carcinoma  to  drag  is  towards  itself  the  sur- 
ronnding  apparently  healthy  tissues  is  an  inevitable  consequence  of 
the  process  of  perilymphatic  fibrosis,  for  the  contraction  of  the  new 
fibrous  tissue  threads,  replacing  the  normal  network  of  lymphatic 
vessels,  leads  to  a  general  puckering  and  shrinkage  of  the  affected 
zone.  The  process  of  perilymphatic  fibrosis  is  especially  interesting 
because  it  is  an  example  of  the  local  cure  of  cancer  by  natural  pro- 
cesses (see  p.  69).  But  the  cure  is  local  only,  for  the  fibrotic  process  / 
fails  to  overtake  the  spreading  edge  of  permeation,  which  has  mean- \ 
time  invaded  new  districts  of  the  lymphatic  system 

( hving  to  the  regular  centrifugal  spread  of  permeation  in  an  ever- 
widening  circle  away  from  the  primary  growth,  three  zones  of  cancerous 
infection  can  be  distinguished  around  the  obvious  primary  growth. 

1.  The  inner  zone  of  isolated  or  confluent  secoyxdary  nodules.  In 
this  zone  the  permeated  lymphatics  have  been  destroyed. 

2.  A  narrow  zone  in  which  perilymphatic  fibrosis  is  actively  pro- 
gressing, and  in  which  invasion  of  the  layers  adjacent  to  the  main 
lymphatic  plexus  is  seen  in  an  early  stage. 

3.  The  microscopic  growing  edge  or  outer  zone  of  fascial  permeation. 
This  zone  is  clinically  inappreciable,  for  the  infection  is  purely  micro- 
scopic. The  lymphatic  vessels  are  choked  by  cancer  cells,  while 
infiltration  is  absent — that  is  to  say,  the  interstices  of  the  tissues  are 
free  from  cancer  cells.  The  microscopic  growing  edge  is  found  in 
the  plane  of  the  deep  fascia  where  the  main  lymphatic  plexus  is  • 
situated.  The  clinical  importance  of  this  fact  cannot  be  over 
estimated. 

The  detection  of  the  microscopic  growing  edge  in  the  deep  fascia 
is  the  primary  fact  upon  which  the  permeation  theory  rests.  It  is 
a  zone  but  a  few  millimetres  wide,  and  it  can  only  be  detected  by 
taking  sections  radiating  from  the  growth  far  into  apparently  healthy 
tissues,  and  by  examining  these  sections  in  their  whole  length.  But 
this,  the  true  growing  edge  of  the  cancer,  though  inappreciable  by 
ordinary  methods  of  examination,  is  just  as  definite  and  real  as  the 
visible  spreading  edge  of  a  ringworm  or  of  a  tertiary  syphilide.  At 
first  the  microscopic  growing  edge  forms  a  small  circle  immediately 
around  the  growth,  but  it  constantly  increases  in  size  until  it  may 
attain  a  diameter  of  2  ft.,  involving  the  scalp  above,  reaching  the 
groins  below,  and  enveloping  the  back. 


02  THE   BREAST 

Visceral  dissemination — Although  the  permeation  theory  of 
dissemination  .-reins  the  only  tenable  one  so  far  as  the  superficial 

metastases  are  concerned,  it  might  appear  at  first  sight  necessary 
to  invoke  the  embolic  theory  to  explain  secondary  deposits  in  the 
viscera.  Careful  investigation  shows  that  this  is  not  the  case.  The 
visceral  metastases  in  breast  cancer  mainly  arise  from  permeation 
along  the  numerous  fine  anastomoses  winch,  piercing  the  parietes, 
connect  the  lymphatic  plexus  of  the  deep  fascia  with  the  subendothelial 
lymphatic  plexuses  of  the  pleura  and  the  peritoneum,  and  with  the 

mediastinal    and    portal 
glands.     But  as  soon  as 
subserous   plexus   is 
bed,    permeation    is 
*ated  to  a  subsidiary 
position,  for   the  cancer 
soon  erode  the  over- 
endothelium     and 
>'*:M\\  ''I     vV,  <#r'ifeiy    ,•."*«•  escape    into    the    serous 

'*.',#■    t         /  *-*'?)    fL'**     >*      ^  '    '^  cavities.     Under  the  in- 

*    y,  ?»'."%•       y         i         *•  t  fluence  of  muscular  move- 

i»     -'i,         g     (    j  "£''-'•'  ments    and    of    gravity. 

*$**,  the   cancer  cells  become 

**  widely  diffused  through- 

out  the  invaded  cavity, 
si  and  implant  themselves 

upon  the  serous  surfaces 

_.  T   „,  of    the    various    organs. 

Fig.     273. — Infiltration    in    breast    cancer.       TT  .  , 

Narrow  columns  of  cancer  cells  are  Here  theF  grow  and 
growing  along  the  cellular  interspaces.  originate  secondary  de- 
x  20.     Cf.  Fig.  274.  posits.      This    mode    of 

cancerous  dissemination 
may  be  called  transcoelomic  implantation.  It  only  occurs  very  late  in  the 
disease,  but  once  initiated  it  rapidly  leads  to  the  death  of  the  patient. 
In  accordance  with  this  view  is  the  fact  that  the  thorax  and  the 
abdomen  may  be  invaded  independently.  That  is  to  say,  after  death 
secondary  deposits  may  be  found  only  in  the  thorax  and  not  in  the 
abdomen,  or  only  in  the  abdomen  and  not  in  the  thorax — a  fact  for 
which  the  embolic  theory  fails  to  account.  Moreover,  as  might  be 
expected,  the  presence  of  serous  (non-cancerous)  adhesions  is  found 
to  delay  dissemination  by  hindering  transcoelomic  implantation.  The 
secondarv  deposits,  too,  in  the  serous  cavities  show  a  preference  for 
the  serous  surfaces  of  the  viscera,  and,  owing  to  the  action  of  gra- 
vity, tend  to  affect  the  lower  limits  of  the  serous  cavities,  especially 
the  pelvis. 


MAMMARY   CANCER:    DISSEMINATION 


*">* 


-v 

• 

V" 

4  i 

i* 

f 

-•  • 

Epigastric  invasion  of  the  abdomen.     According  tn  the  r< 
oi  Btiles,  th<-  Lower  and  inner  margin  of  the  I  erliea  the  sixth 

costal  cartilagi — that  is  to  Bay,  this  pari   of  the  mammary  circum- 
ference is  distant  only  aboul  an  inch  from  the  epigastric  angle.     In 
the  epigastric  angle  the  deep  fascia  is  separated  from  tin-  subperil 
Eat  and  the  peritoneum  only  by  a  Bingle  layer  oi  fibrous  tissue,  the 
lines  alba.     As  soon  as  fascial  permeation  \i;*>  Bpread  an  inch  beyond 
the  margin  « >f  the  breast,  cancer  cells  are  thus  brought   into  close 
proximity  with  the  peritoneal  cavity,  and  they  have  only  to  infiltrate 
the  lines  alba   and  pass 
through   tin4    loose    sub- 
serous fit  before  reaching 
it.      This    mode    of    ab- 
dominal   invasion,   which 
1   have  traced  microscop- 
ically   in    all    its    stages, 
may    be   called   epigastric 
invasion.     Reaching     the 
peritoneum  by  this  route, 
the  cancer  cells  first  im- 
plant    themselves     upon 
the  convex  upper  surface 
of  the  liver,  close  to  the 
falciform  ligament.   Other 
cancer  cells  may  fall  into 
the   pelvis  and    give  rise 
to     deposits     filling     the 
pouch   of  Douglas,  or  to 
secondary     ovarian 
growths.     Epigastric    in- 
vasion   probably    occurs 
sooner  or  later  in  at  least 
one  case  in  three.     It  is 
especially  likely  to  super- 
vene   early     in     cancers 

affecting  the  lower  and  inner  quadrant.  It  may  be  suspected  when 
epigastric  pain  and  tenderness  are  present,  even  apart  from  hepatic 
enlargement  and  jaundice,  and  may  be  diagnosed  with  confidence  if 
subcutaneous  nodules  are  present  in  the  epigastric  region. 

Other  modes  of  invasion  of  the  abdomen. — The  retroperitoneal 
abdominal  organs,  especially  the  liver,  kidneys,  and  suprarenals,  or 
the  lumbar  spine  mav  be  attacked  by  the  downward  extension  of 
permeation  through  the  diaphragm  from  pleural  deposits.  This  may 
be   called   retroperitoneal  invasion   of  the   abdomen.     In   rare 


Fig.  274. — A  permeated  lymphatic  in  longi- 
tudinal section.  The  endothelium  of 
the  lymphatic  is  visible  outside  the 
mass  of  cancer  cells  which  fills  it. 
Above  it  is  seen  a  normal  blood-vessel. 
Infiltration  of  the  tissues  is  absent, 
x  150.     Cf.  Fig.  273. 

{Front  H  andley'  s  ' '  Cancer  of  the  Ftrcast  and  i:s 
Operative   Treatment. ' ' ) 


64 


THE    BREAST 


the  peritoneal  cavity  may  be  reached,  when  the  pleura  is  already 
cancerous,  by  cancerous  infiltration  of  the  anterior  portion  of  the 
diaphragm   (diaphrenic  invasion). 

Invasion  of  the  thorax. — Breast  cancer  may  reach  the  interior  of 
the  thorax  in  several  ways,  (a)  Permeation  may  extend,  by  means 
of  lymphatic  anastomoses  piercing  the  anterior  end  of  the  intercostal 
spaces,  to  the  anterior  mediastinal  glands,  and  thus  to  the  other 
thoracic  glands  and  to  the  pleura.  Fortunately  this  is  not  common, 
for  cancerous  anterior  mediastinal  glands  are  found  in  only  6-5  per 
cent,  of  necropsies  on  breast  cancer,  (b)  The  pleural  cavity  may 
be  invaded  by  direct  infiltration  of  the  chest  wall  beneath  the  primary 
growth,  (c)  Cancerous  supraclavicular  glands  may  become  adherent 
to  the  dome  of  the  pleura.  Subsequently,  cancer  cells  infiltrate  the 
pleura  and  escape  into  the  pleural  cavity. 

Thoracic  dissemination  may  be  delayed  or  prevented  by  the 
presence  of  old   pleural   adhesions. 

Secondary  deposits  in  the  brain. — Secondary  deposits  occur  in  the 
brain  in  about  4  per  cent,  of  cases,  and  in  the  dura  mater  with  about 
the  same  frequency.  They  may  be  due  to  blood  invasion,  but  often 
they  result  from  upward  permeation  along  the  cervical  lymphatics 
from  enlarged  supraclavicular  glands. 

Permeation  and  infiltration  contrasted. — Some  recent  writers 
have  used  the  terms  permeation  and  infiltration  indiscriminately, 
and  it  will  be  well  to  lay  down  clearly  the  differences  between 
these  two  modes  of  spread  of  carcinoma,  and  to  indicate  their  rela- 
tive importance. 


Infiltration  (Fig.  273) 

In  point  of   time,   the    earliest   dis- 

serninative  process. 
Best  seen  at  the  edge  of  the  primary 

growth,  as  defined  by  the  naked 

eye. 


The  cancer  cells  are  spreading  along 
the  tissue  interspaces,  e.g. 
between  fat  cells,  or  between 
adjoining  fibrous  bundles.  (See 
Fig.  273.) 

If  infiltrating  cancer  cells  intrude 
into  a  capillary  lymphatic  vessel 
the  process  of  infiltration  merges 
into  that  of  permeation. 


Permeation  (Fig.  274) 

In  point  of  time,  begins  after 
infiltration. 

Best  seen  at  the  microscopic  growing 
edge,  which,  in  advanced  cases, 
may  be  situated  in  apparently 
normal  tissues,  6  in.  or  more 
from  the  apparent  edge  of  the 
primary  growth. 

The  lymphatic  vessels,  not  the 
lymphatic  spaces,  are  filled  up 
and  choked  by  solid  cords  of 
cancer  cells.  The  tissue  inter- 
spaces are  free  from  cancer  cells. 
{See  Fig.  274.) 

If  a  permeated  lymphatic  ruptures, 
the  cancer  cells  set  free  may 
infiltrate  the  surrounding  tissues. 
Thus  permeation  may  lead  to 
infiltration. 


"PEAU    D'ORANGE" 

Infiltration  is  a  very  bIcto    pro  Permeation  is  a  more  rapid  process 

because  of  the  resistance  offered  than    infiltration,    because    tho 

to  the  passage  of  oancer  oells  oancer  cells 

through  the  cramped  and  tor.-  little  resistance  along  the  open 

tuous  tissue  intersp  lumen  <<i  the  lymphatic  vessels. 

Infiltration,  <>n  account  of  its  slow-         Permeation  may  carry  cancer  cells 
ness,  is  of  relative  unimportance  to  a  very  considerable  distance 

i  factor  in  general  dJasemina-  from  the  primary  tumour,  and 

ti"ii.  is    capable    of    traversing    the 

minute  anastomotic  lymphatic 
plexuses.  It  is  accordingly  tho 
|n incipal  factor  In  general  dis- 
semination. 

Summary. — It  will  be  clear  from  what  has  been  said  that  the 
processes  concerned  in  dissemination  are  mainly  three  in  number — 
(a)  permeation,  (b)  infiltration,  (c)  transccelomic  implantation.  To 
these  must  be  added,  as  playing  subsidiary  parts — (d)  lymphatic 
embolism,  which  leads  only  to  gland  deposits,  and  (e)  blood  embolism, 
which  is  usually  ineffective  owing  to  the  inability  of  the  cancer  cells 
to  colonize  the  blood-stream. 

Effects  of  lymphatic  obstruction  in  breast  cancer. 

— Certain  of  the  later  manifestations  of  breast  cancer  do  not  depend 
upon  actual  cancerous  growth,  but  upon  interference  with  the  return 
of  lymph  from  the  affected  part  owing  to  obstruction  of  its  lymphatics 
by  permeation  and  perilymphatic  fibrosis.  The  changes  due  to 
lymphatic  obstruction  are  seen  in  the  skin,  the  arms,  and  the  serous 
cavities,  and  need  brief  separate  consideration  in  each  of  these 
situations. 

"  Pig-skin,"  or  "  peau  d'orange." — One  of  the  most  charac- 
teristic signs  of  cancer  of  the  breast  in  a  somewhat  advanced,  though 
perhaps  still  operable,  stage  is  the  appearance  known  as  pig-skin  or 
peau  d'orange.  In  this  condition  the  orifices  of  the  sebaceous  glands, 
normally  just  visible,  become  enlarged  and  deepened,  to  form  obvious 
dotted  depressions,  sometimes  blackened  and  emphasized  by  ingrained 
dirt.  The  affected  skin  is  obviously  thick  and  leathery,  and  has  lost 
its  suppleness.  It  overlies  the  carcinoma,  and  is  usually  adherent  to 
it,  but  later  the  surrounding  skin  may  be  involved  to  a  considerable 
distance  (Fig.  275).  It  is  sometimes  erroneously  stated  that  orange- 
rind  integument  is  seen  only  in  carcinoma.  Although  due  to  cancer 
in  nearly  all  cases,  it  \may  occur  in  syphilis,  in  tubercle,  in  cold 
abscess  of  the  breast,  and  in  elephantiasis^) 

Pathology. — It  has  been  taught  until  recently  that  peau  d'orange 
depends  upon  the  anchorage  of  the  breast  to  the  overlying  skin  by 
means  of  the  fibrous  bands  called  the  ligaments  of  Astley  Cooper, 
and  that  it  is  produced  by  the  contraction  of  these  ligaments  following 

/ 


66  THE   BREAST 

their  invasion  by  growth.  This  view  appears  to  hold  an  element  of 
truth,  but,  since  an  identical  appearance  may  be  seen  upon  the  skin 
in  elephantiasis,  the  explanation  is  incorrect.  Leitch  has  shown 
convincingly  that  the  appearance  is  produced  by  swelling  of  the  skin 
due  to  lymphatic  stasis,  i.e.  by  lymphatic  oedema.  Where  the  skin 
is  transfixed  by  hair-follicles  it  is  unable  to  swell,  and  at  these  points 


Fig.  275. — Carcinoma  of  the  breast,  showing  retraction  of  the 
nipple,  and  marked  and  extensive  peau  d'orange. 

obvious  pits  are  seen,  comparable  to  the  buttoned  depressions  in  a 
stuffed  arm-chair.  The  occurrence  of  the  lymphatic  obstruction  is 
explained  by  the  facts  of  permeation  (see  p.  60). 

Cancerous  pachydermia  (cancer  en  cuirasse) — In  certain 
cases  of  breast  cancer  the  skin  over  and  round  the  tumour  becomes 
hypertrophied,  leathery,  and  thickened.  The  condition  just  described 
as  pig-skin  is  the  earliest  sign  of  this  pachydermatous  change.  Usually 
the  skin  retains  its  normal  colour  and  does  not  pit  on  pressure.  In 
the  late  stage  of  the  affection,  cancerous  nodules,  which  may  ulcerate, 


Carcinoma  of  tne  breast  of  atrophic  type,  showing  early  "cancer  en  onrasse. 
The  breTst  and  skin  are  firmly  fixed  to  the  thorax.      Lymphatic  oedema  of  the 
skin's  present  as  high  as  the   clavicle  and  beyond  the  nuddle  hne  m  front. 

(See  p.  66.) 


-     .,-  r  i/v     i    A'    Mitchell  of Belfast,  to  wfunn  the  author 

(Fro,,  a  case  unac,  tne  —gjfc  foioteffhot^{fh  {ere  'reproduced. , 

PLATE  81. 


•indebted 


MAMMARY   CANCER  67 

appear  bere  and  there  in  the  affected  area,  and  the  -kin.  previously 
leathery,  now  becomes  bard  and  brawny,  purplish  or  red  in  colour, 
and  perhaps  covered  by  rough  desquamating  crusts.  Cancerous 
pachydermia  first  appears  over  th>-  primary  growth  and  spreads  from 
it  in  all  directions,  involving  an  increasing  and  roughly  circulai 
which  ultimately  includes  the  whole  of  the  front  of  the  chest,  and 
encroaches  on  the  abdomen,  Deck,  and  back.  It  is  usually 
ciated  with   "brawny  aim."  and  in  it-  latest  'th  arms  may 

be  swollen  (Kg.  l';»'.  and   Plate  81), 

In  an  extreme  instance  of  cancerous  pachydermia  recorded  by  Velpeau, 
.111  was  affected  fnun  tin-  umbilicus  t.>  tin-  larynx,  and  from  the  loins 
to  the  occiput.  The  thickened  skin  was  sown  with 
closely-set  cancerous  l»>-ses.  The  arms  were  tripled  in  bulk,  and  as  hard 
as  marble.  The  respiration  resembled  that  of  a  person  whose  <i 
grippe!  in  a  vice,  and  the  arms  and  bead  were  immovable,  while  pain  in 
the  arms  was  constant  and  terrible,  so  that  the  sufferer  longed  for  death. 
In  such  cases,  asphyxia  may  be  the  actual  cause  of  death. 

The  condition  I  have  just  described  was  regarded  until  recently 
as  due  to  cancerous  invasion  of  the  skin,  and  this  view  is  correct  as 
Is  the  later  stages.  But  if  the  thickened  skin  be  examined  in 
the  early  stage  of  leathery  hypertrophy  no  cancer  cells  can  be  found 
in  it.  and  I  have  shown  that  the  condition  is  one  of  lymphatic 
oedema,  the  changes  being  identical  witli  those  met  with  in  the 
skin  of  elephantiasis.  The  altered  skin  of  the  breast  may  some- 
times attain  a  thickness  of  6  mm.  before  any  cancer  cells  can  be 
detected  in  it. 

The  factor  which  causes  lymphatic  obstruction  is  cancerous  per- 
meation and  subsequent  fibrotic  obliteration  of  the  underlying  fascial 
lymphatic  plexus  and  its  tributaries.  The  name  cana  rous  pachy- 
dermia is  thus  the  most  appropriate  which  can  be  found.  The 
name  cancer  en  cuirasse  should  be  reserved  for  the  later  stage  of 
cancerous  pachydermia  in  which  the  skin  shows  nodular  or  diffuse 
cancerous  infiltration. 

The  "  brawny  arm"  of  breast  cancer. — In  a  late  stage  of  breast 
cancer  the  corresponding  arm  often  becomes  swollen  and  oedematous. 
At  first  the  eedema  pits  on  pressure,  but  it  soon  becomes  solid  and 
brawny.  The  arm  is  the  seat  of  an  unbearable  heavy  dragging  pain, 
and  may  attain  a  size  twice  or  three  times  its  normal  volume.  The 
skin  is  tense  and  shiny.  Muscular  power  is  gradually  lost,  until 
complete  paralvsis  results.  This  condition  has  been  ascribed  to  venous 
obstruction,  a  view  shown  to  be  incorrect  by  the  absence  of  oedema 
after  resection  of  the  axillary  veins.  It  has  been  said  to  be  due  to 
obstruction  of  the  lymphatic  trunks  by  growth  outside  or  within 
them.     If  this  were  the  case  it  should  invariably  occur  in  an  early 


68  THE   BREAST 

stage  of  the  disease,  for  cancerous  infiltration  of  the  axillary  glands 
must  necessarily  obstruct  the  trunks  which  lead  to  them.     In  point 


Fig.  276. — Carcinoma  of  the  breast  in  a  late  stage,  showing  carreer 
en  cuirasse  and  an  extreme  degree  of  lymphatic  swelling  of  the 
arm.  The  swelling  extends  to  the  shoulder,  and  on  this  account 
the  case  is  not  a  suitable  one  for  lymphangioplasty. 

of  fact,  lymphatic  oedema  of  the  arm  is  a  consequence  of  the  spread 
of  permeation  to  the  lymphatic  plexuses  about  the  shoulder,  and  of 
the  subsequent  conversion  of  the  permeated  vessels  into  solid  cords 


MAMMARY  CANCER:    NATURA1     REGRESSION 

of   fibrous   tissue.     The   arm    is   thus   completely   cut    of!   from   the 
lymphatic  circulation.     X<>  collateral  circulation  can   be  establ 
;ind  the  limb  necessarily  tails  into  a  conditi if  lymphatic  oedema. 

The  treatment  of  this  condition  is  discussed  a1  p.  95. 

Serous  effusions  in  breast  cancer.  The  collection  of  fluid 
in  the  Berous  cavities  is  a  sign  that  the  patient  has  at  most  bul 
months  to  live.  Sometimes  pleuritic  effusion  appears  only 
or  two  before  death,  and  in  Buch  cases  it  is  due  to  terminal  heart- 
failure.  But  generally  it  appears  to  depend  upon  lymphatic  obetruc- 
t ic m.  and  more  especially  upon  permeation  oi  the  subpleural  lymphatic 
plexus,  which  may  be  completely  injected  with  cancer  cells  (so-called 
lymphangitis   carcinomatosa).     This    condition    is    recognizable 

mi  by  the  naked  eye.     The  pressure  of  enlarged  cancerous  glands 
must  also  be  regard"  luse  of  pleuritic  effusion.     Similar  factors 

are  at  work  in  causing  ascites,  and  the  distension  of  the  abdomen 
may  be  extreme.  It  is  thus  obvious  that  lymphatic  obstruction  is 
often  the  proximal  cause  of  death  in  breasl  cancer. 

Serous  effusions  causing  distress  should  be  treated  by  aspiration, 
but  sometimes  the  interference  is  not  worth  while. 

Natural  regression  or  repair  in  breast  cancer. — 
The  close  observation  of  breast  cancer  has  shown  that  occasionally, 
in  cases  running  their  natural  course,  and  in  the  absence  of  all  treat- 
ment, subcutaneous  secondary  deposits  may  shrink  and  disappear, 
enlarged  glands  may  become  impalpable,  cancerous  ulcers  may  com- 
pletely heal,  and  osseous  union  may  take  place  in  bones  fractured  as 
the  result  of  secondary  deposits. 

One  case  recorded  by  Pearce  Gould  presented  numerous  thoracic  sub- 
cutaneous nodules,  enlarged  and  hard  glands  above  the  clavicles  and  in 
the  axilla',  spontaneous  fracture  of  the  left  lemur,  and  great  dyspnoea  and 
emaciation.  All  the  deposits  spontaneously  disappeared  within  a  few 
months,  and  the  patient  remained  well  for  at  least  three  years,  when  she 
was  lost  sight  of. 

The  most  probable  explanation  of  these  facts  is  that  certain  pro- 
cesses of  repair,  which  in  exceptional  cases  may  become  clinically 
manifest  by  the  disappearance  of  massive  secondary  deposits,  are  a 
normal  part  of  the  cancer  process.  In  a  mass  of  cancer  cells,  owing 
to  nutritional  difficulties,  the  central  portions  sooner  or  later  become 
fibrotic  and  degenerate,  a  fact  clinically  shown  by  the  almost  invariable 
ulceration  which  occurs  in  primary  growths  and  by  the  umbilication 
found  in  secondary  deposits  in  the  liver.  The  process  of  repair  tends 
to  spread  from  the  centre  of  the  mass  to  its  circumference,  and  its 
ultimate  outcome,  unless  the  death  of  the  patient  intervenes,  is  the 
replacement  of  the  mass  of  cancer  cells  by  a  fibrous  Mar.  Thus  in 
chronic  cases  the  older  secondary  deposits  may  be  reduced  to  fibroid 


7o  THE   BREAST 

masses  in  which  no  epithelium  can  be  detected.  But  the  fibrosis 
and  cure  of  the  older  deposits  dors  not  interfere  with  the  process  of 
dissemination  or  delay  the  fatal  event. 

Degeneration  in  carcinoma.  —  The  improvised  vascular 
arrangements  of  a  carcinoma  frequently  prove  insufficient  to  meet  the 
needs  of  the  rapidly  growing  cell  masses  which  fill  the  meshes  of  the 
stroma.  Since  these  masses  are  themselves  avascular,  there  comes 
a  time  when  the  central  cells  of  each  alveolus,  cut  off  from  their  base 
of  supply,  degenerate  and  die.  They  may  necrcse,  or  liquefy,  or 
change  into  colloid  material.  In  some  cancers  these  changes  are  only 
recognizable  by  the  microscope ;  in  others  large  visible  areas  of  the 
tumour  are  affected. 

Necrotic  changes. — The  greyish  appearance  which  most  car- 
cinomas present  on  section  is  probably  due  to  early  necrotic  changes. 
In  more  marked  instances,  areas  of  necrotic  material  are  seen  as 
greyish  dots  upon  the  cut  surface,  and  exude  as  plugs  resembling 
sebum  when  the  tumour  is  compressed.  Microscopically,  necrotic 
cells  fail  to  stain,  and  present  a  granular  homogeneous  appearance. 
Here  and  there  cell  outlines  may  still  be  recognizable. 

Liquefaction. — In  some  carcinomas  each  fully  developed  alveolus 
presents  histologically  a  central  cystic  cavity,  often  containing  many 
leucocytes.  Occasionally,  larger  cysts  containing  clear  serous  fluid 
may  be  formed. 

Colloid  degeneration. — Colloid  is  a  material  closely  allied  to 
mucus,  formed  by  the  degeneration  of  the  epithelium  of  a  carcinoma. 
At  first  the  stroma  does  not  share  this  change,  but  remains  unaltered, 
enclosing  spaces  filled  with  clear  jelly-like  colloid  material.  In  naked- 
eye  specimens,  unaltered  vessels  and  areas  of  tissue  which  have 
escaped  degeneration  may  be  seen  embedded  in  a  translucent  mass 
of  colloid.  Colloid  degeneration  can  usually  only  be  diagnosed  when 
the  breast  is  cut  across,  and  it  has  little  clinical  importance.  In  the 
specimens  I  have  seen,  the  cancer  has  been  usually  rather  movable 
and  of  slow  growth,  and  the  patient  beyond  middle  age.  The  signs 
dependent  upon  contraction,  such  as  retraction  of  the  nipple,  are 
usually  absent. 

Calcareous  degeneration  has  been  recorded  in  the  more  fibroid 
forms  of  carcinoma. 

Pathological    classification   of  the   signs  of   breast 

cancer. — The  signs  of  breast  cancer  may  be  divided  into  classes  : — 

a.  Those  dependent  upon  the  presence  of  the   primary  growth, 

and  upon   its   infiltrative  tendencies  (fixity  of  the  tumour 

in  the  breast,  adhesion  to  skin  and  fascia). 

B.  Those   dependent    upon    permeation    and  subsequent  fibrosis 

of  the  lymphatics  of  the  surrounding  districts  (dimpling  of 


MAMMARY    CANCER  :   SIGNS  71 

the  skin,  shrinking  of  the  breast,  elevation  and   retraction 

of  t  he  nipple), 
c.  Those  dependenl    upon    lymphatic    obstruction   (orange-rind 

skin,  brawny  arm,  serous  effusions). 
D.  Those  dependent  on  fibrosis  and  failure  of  nutrition  in  the 

centra]  parts  of  the  older  deposits  (ulceration  of  primary 

growth,  ulceration  or  umbilication  of  the   older  secondary 

deposits). 
e.  Those  dependenl    upon  the  formation  of  satellite  or  m 

tatic  nodules — 

1.  In  the  lymphatic  glands,   from  Lymphatic  embolism. 

2.  In  continuity  with  the  primary  growth,  as  terminal  out- 

crops of  long  lines  of  lymphatic  permeation. 

3.  In  the  viscera  and  serous  membranes,  from  invasion  of  the 

serous    cavities    and  subsequenl    transccelomic  implanta- 
tion. 
1.  Those  resulting  from  blood  embolism. 

Symptoms  and  signs.— It  is  unfortunate  thai  in  the  earliest 
of  breasl  cancer  the  signs  are  equivocal.  .Most  of  the  classical 
signs  are  not  produced  by  the  growth  itself,  but  by  the  fibrotic  pro- 
cesses which  are  the  reaction  of  the  organism  to  the  invading  epithe- 
lium. Thus  they  are  only  available  when  the  disease  has  already 
made  a  certain  amount  of  progress.  A  patient  with  cancer  may 
appear  well  nourished  and  in  excellent  general  health.  The  so-called 
cancerous  cachexia  is  a  late  sign,  often  produced  by  septic  absorption 
from  an  ulcerated  primary  growth,  or  due  to  the  habitual  use  of 
morphia. 

First  sign  noticed  by  the  patient. — In  four-fifths  of  the  ca 
of  mammary  cancer  the  patient  is  led  to  seek-  advice  because  she  finds 
a  lump  in  the  breast.  In  a  few  of  these  cases  an  occasional  sharp 
twinge  of  pain  has  led  to  the  detection  of  the  lump,  but  as  a  rule  pain 
and  discomfort  have  been  conspicuous  by  their  absence.  It  is  rare 
to  find  a  cancer  in  a  patient  whose  only  complaint  is  of  mammary 
pain.  If  the  patient  comes  complaining  of  severe  pain  and  a  cancer 
is  found,  the  growth  is  usually  so  far  advanced  as  to  be  inoperable. 
The  patient  may  have  recognized  and  concealed  its  existence  for  a 
long  period,  perhaps  for  years,  or,  if  exceptionally  unobservant,  she 
may  not  have  noticed  the  lump.  Occasionally  a  lump  in  the  axilla 
may  be  noticed  by  the  patient  before  she  detects  anything  wrong 
with  the  breast.  Discharge  or  bleeding  from  the  nipple,  retraction 
of  the  nipple,  discoloration  or  puckering  of  the  skin,  contraction  or 
ulceration  of  the  breast,  swelling  of  the  arm,  pain  in  the  spine,  hip,  or 
abdomen,  fracture  of  the  femur,  an  abdominal  swelling,  or  signs  of 
paraplegia — each  of  these  conditions  may  be  exceptionally  the  reason 


72  THE    BREAST 

assigned  by  the  patient  for  seeking  advice.  Many  of  these  signs  imply 
an  advanced  degree  of  dissemination,  so  that  the  disease  is  hopeless 
when  first  seen.  The  causes  of  this  regrettable  fact  are  feelings  of 
delicacy,  dread  of  operation,  and  the  insidious  and  painless  course 
of  the  disease  in  its  earlier  stages. 

The  signs  of  breast  cancer  will  now  be  separately  described,  one 
by  one,  in  the  order  of  their  appearance.  The  order  is,  however,  far 
from  being  constant. 

Presence  of  a  lump  in  the  breast.  —  The  primary  growth 
usually  forms  a  definite  localized  lump  in  the  breast,  characteristic- 
ally single,  of  stony  hardness,  palpable  with  the  flat  hand,  and  fixed 
in  the  substance  of  the  breast.  In  the  early  stage  the  small  lump 
may  be  mobile  and  indistinguishable  from  an  innocent  tumour,  and 
all  other  signs  of  carcinoma  may  be  absent.  It  is  the  surgeon's  ideal 
to  detect  and  remove  the  carcinoma  in  this  stage,  and  in  all  such 
doubtful  cases  the  diagnosis  should  be  completed  without  delay  by 
an  exploratory  operation,  especially  if  the  patient  is  over  30. 

Dimpling  or  retraction  of  the  skin.— This  is  one  of  the  ear- 
liest signs  of  the  carcinomatous  nature  of  a  small  lump  in  the  breast, 
and  perhaps  the  most  valuable.  Dimpling  is  sometimes  obvious  to 
the  eye  (Fig.  277),  but  careful  manipulation  and  close  observation  are 
necessary  to  appreciate  the  slighter  degrees,  which  are  of  great  value 
and  significance.  The  finger  and  thumb  placed  firmly  upon  the 
skin  on  opposite  sides  of  the  growth  are  to  be  slowly  approximated. 
In  carcinoma  the  convex  fold  of  skin  which  is  thrown  up  by  this 
manoeuvre  presents  upon  its  summit  a  slight  and  very  shallow  cir- 
cular depression  ;  or  a  definite  fold  may  fail  to  make  its  appearance, 
and  may  be  replaced  by  a  number  of  ill-defined  wrinkles. 

Another  method  of  demonstrating  retraction  is  to  push  the  whole 
breast  in  the  direction  of  the  area  of  skin  to  be  tested.  Owing  to 
its  attachments  to  the  underlying  tumour  a  local  depression  appears 
upon  this  area  of  skin. 

Adhesion  of  the  skin.— In  the  earlier  stages  of  dimpling  the 
skin  still  moves  over  the  subjacent  growth  ;  but  later,  actual  adhesion 
becomes  manifest  over  the  centre  of  the  growth.  The  pig-skin  or 
peau  <K  orange  appearance  is  now  usually  seen  (see  Fig.  275  and  p.  65). 

Adhesion  to  the  pectoral  fascia. — Early  cancerous  growths 
move  freely  with  the  breast  over  the  subjacent  pectoral  fascia  ;  but 
in  a  comparatively  early  stage,  especially  if  the  growth  is  deeply 
situated  in  the  breast,  signs  of  fixation  of  the  growth  to  the  fascia 
become  manifest.  Careful  attention  to  detail  is  necessary  to  demon- 
strate this  sign.  Either  by  the  patient's  voluntary  contraction  of 
the  great  pectoral,  or  better  by  passively  elevating  the  arm,  the  fibres 
of  this  muscle  are  made  taut.     The  growth  is  grasped  in  the  hand 


MAMMARY   CANCER  :    SIGNS 


and  ia  moved  to  and  faro  in  a  direction  parallel  to  the  fibres  «»f  the 
muscle.  Partial  or  complete  fixation  may  thue  be  detected.  fcfov< 
merits  a1  right  angles  to  the  fibres  is,  "l  course,  presenl  even  when  the 
growth  is  completely  fixed  to  the  muscle.  Deep  growths  become 
fixed  to  the  muscle  before  adhesion  to  the  skin  ie  evident,  while  in 
superficial  ones  the  reverse  is  the  case. 


Fig.  277. — Absence  of  retraction  of  the  nipple  in  advanced  breast 
cancer.  Note  the  presence  of  peau  d'orange,  and  of  extensive 
puckering  and  adhesion  of  the  skin. 

Local  flattening  of  the  contour  of  the  breast. — Lenthal 
Cheatle  has  drawn  attention  to  local  flattening  of  the  curved  con- 
tours of  the  breast,  when  the  organ  is  viewed  in  profile,  as  a  sign  of 
carcinoma. 

Enlargement  of  the  axillary  glands.  —  This  sign  is  often 
present  by  the  time  the  patient  seeks  advice.  The  prognosis  is  more 
favourable  in  cases  where  the  cancer  has  not  yel  affected  the  glands. 
The  glands  on  the  same  side  as  the  tumour  become  unduly  palpable, 
hard,  and  inelastic.  A  little  later  they  are  definitely  enlarged,  hard. 
and  mobile,  but  not  tender.  Only  in  inoperable  cases  do  they  become 
fixed  to  the  skin  or  to  the  thoracic  wall.  To  examine  the  axilla  the 
arm  is  slightly  abducted,  and  the  fingers,  made  into  a  cone,  are  p 


74 


THE    BREAST 


upwards  as  high  as  possible  along  t he  outer  wall  of  the  axilla.  The 
palmar  surfaces  are  then  pressed  against  the  inner  wall,  and  are  slowly 
drawn  downwards  .-till  firmly  pressed  against  it.  If  enlarged  glands 
are  present  they  will  be  felt  to  slip  past  the  descending  finger-tips. 

Meantime  the  pec- 
torals must  be  re- 
laxed, the  patient 
allowing  the  arm 
to  hang  loosely  by 
her  side. 

Retractipn 
and  eievation,of 
the  nipple. — Re- 
traction of  the  nip- 
ple occurs  in  one 
out  of  four, 
and  when  pi 
usually  indicates 
proximity  of  the 
primary  growth  to 
the  nipple.  The 
nipple  is  first  flat- 
tened, and  then  in- 
drawn, so  that  a 
conical  depression 
replaces  an  eleva- 
tion (Fig.  275).  The 
absence  of  retrac- 
tion (Fkr.  l'77)  pos- 
_rnifi- 
cance  unless  the 
growth  is  near  the 
nipple,  nor  is  its 
presence  significant 
unless  the  nipple 
has  pre  viously  been 
normal.  In  cases  of 
atrophic  scirrhus.  retraction  of  the  nipple  may  precede  the  appear- 
ance of  a  tumour,  and  may  be  the  earliest  change  noted. 

The  whole  breast  is  often  drawn  up  towards  the  pectoral  fascia, 
so  that  the  nipple  is  situated  on  a  higher  level  than  that  of  the  sound 
side.  This  sign  is  a  consequence  of  extensive  perilymphatic  fibrosis 
in  the  lymphatics  of  the  breast. 

The  foregoing  signs  may  all  be  present  in  cases  which  are  still 


278. — Case  of  true  primary  carcinoma  of 
each  breast.  The  carcinoma  on  the  patient's 
right  side  developed  twelve  years  after  the 
removal  of  a  carcinoma  of  the  left  breast. 


MAMMARY   CANCER  :    SIGNS 

favourable  ones  for  operation.     Those  now  to  be  described  indicate 
that    the   case,   though    perhaps   -till   suitable    for   operation, 
unfavourable  one. 

Shrinkage  of  the  breast.     The  whole  breasl  in  fibrotic  growths 
becomes  flattened  and  Bmaller  than  its  fellow,  owing  to  the  conver- 
sion of  it-  permeated   lymphatic   vessels  into  a  network  <>f  thread 
of  fibrous  tissue. 

Ulceration  of  the  growth.  -Adhesion  of  the  skin  is  Boon 
followed  by  discoloration,  infiltration',  and  ulceration.  The  ulcer  has 
a  Bloughy,  irregular  base  and  thickened  rampart-like  edges,  and  the 
skin  around  it  is  puckered  and  indrawn.  On  the  average,  ulceration 
begins  two  and  a  half  years  from  the  time  when  the  disc. 
noticed.  Unless  the  ulcer  is  kepi  aseptic  by  local  applications  it. 
gives  rise  to  a  thin  offensive  discharge,  sloughs  form  upon  its  surface, 
and  serious  haemorrhage  may  occur.  .Many  cancers  are  inoperable  by 
the  time  ulceration  begins,  but  this  is  by  no  means  invariably  the  case. 

Pain  in  the  breast. — It  is  an  unfortunate  fact  that,  as  in  cancer 
generally,  pain  is  not  an  early  symptom  of  cancer  of  the  breast.  As 
a  rule  the  onset  of  serious  pain  coincides  with  t he  appearance  oi 
ulceration,  but  in  rare  cases  pain  may  be  absent  almost  throughout. 
It  is  usually  described  as  pricking,  throbbing,  or  stabbing  in  character. 
The  really  severe  pains  of  breast  cancer  occur  in  the  inoperable  -: 
and  are  then  associated  either  with  supraclavicular  deposits  pre^mLr 
upon  the  brachial  plexus,  with  lymphatic  cedema  of  the  arm,  or  with 
spinal  deposits,  or  other  deposits  in  the  bones. 

Nodular  invasion  of  the  surrounding  skin  is  a  very  un- 
favourable sign,  and  if  t'he  nodules  extend  more  than  2  in.  from  the 
primary  growth  the  case  should  be  looked  upon  as  inoperable,  for 
the  area  of  fascial  permeation  will  be  too  large  for  removal. 

Enlargement  of  the  supraclavicular  glands  is  regarded  by 
some  authorities  as  placing  a  case  in  the  inoperable  category.  But 
if  the  glands  are  still  mobile,  operation  should,  in  my  opinion,  be 
advised. 

The  conditions  which  render  a  case  of  breast  cancer  inoperable 
are  detailed  at  p.  88. 

Diagnosis. — It  is  desirable  that  breast  cancer  should  be  operated 
upon  before  the  signs  of  adhesion  and  contraction  have  manifested 
themselves — that  is  to  say,  before  the  disease  is  clinically  recognizable. 
This  object  can  only  be  attained  by  exploring  all  doubtful  tumours 
of  the  breast  occurring  in  patients  over  30  years  of  age. 

The  conditions  which  most  closely  simulate  breast  cancer  are 
chronic  mastitis,  a  deep  cyst,  especially  if  surrounded  by  an  area  of 
chronic  mastitis,  a  fibro-adenoma  situated  in  an  area  of  chronic 
mastitis,  a  gumma  of  the  breast,  and  tuberculosis. 


76 


THK    BR K AST 


The  diagnosis  between  chronic  mastitis  and  cancer  may  here  be 
summed  up  in  tabular  form  : — 


Chronic  Mastitis 

A  mobile  induration  uniformly  and 
finely  granular,  only  vaguely 
palpable  with  the  Hat  hand. 

Indurations  often  multiple. 

Indurations  sector-shaped,  mapping 
out  the  limits  of  one  or  more 
lobes  of  the  breast. 

Indurated  areas  often  tender  and 
may  be  the  seat  of  pain. 

The  indurated  areas  do  not  adhere  to 
skin  or  to  fascia. 

Axillary  glands  only  slightly  enlarged, 
of  ten  distinctly  tender,  not  hard. 

Nipple  not  retracted. 
Skin  normal. 


( '  LRCINOM  \ 

A  definite  lump  lixed  in  the  breast 
and  easily  palpable  with  the 
flat  hand. 

A  single  lump. 

The  lump  isTnore  or  less  rounded, 
and  does  not  respect  the  anato- 
mical boundaries  which  separate 
adjoining  lobes. 

Lump  neither  painful  nor  tender. 

Lump  usually  (hut  not  necessarily) 
shows  signs  of  adhesion  to  skin 
or  fascia,  or  both. 

Axillary  glands  often  (hut  not  neces- 
sarily) enlarged,  hard  and  not 
tender. 

Nipple  may  be  retracted. 

Skin  may  present  the  orange-rind 
appearance. 


Diagnosis  is,  however,  complicated  by  the  fact  that  a  carcinoma 
may  arise  in  an  area  of  chronic  mastitis.  A  local  lump  in  the 
midst  of  a  sector-shaped  area  of  granular  induration  may  be  a 
cyst,  a  fibro-adenoma,  or  an  '  early  carcinoma.  Multiple  rounded 
and  movable  lumps  will  probably  prove  to  be  cysts  ;  a  single  and 
fixed  one  is'  often  a  carcinoma,  and  imperatively  demands  explora- 
tion. Only  in  cases  where  the  indurations  are  vague,  sector-shaped, 
and  uniformly  and  finely  granular  can  a  carcinoma  be  excluded 
with  certainty.  In  the  large  class  of  doubtful  cases,  experience  alone 
can  decide,  and  less  harm  is  done  by  exploring  unnecessarily  than 
by  awaiting  the  full  development  of  a  carcinoma.  Nevertheless, 
routine  operations  in  chronic  mastitis  are  much  to  be  deprecated. 

A  cyst  deeply  situated  in  the  breast  of  a  stout  patient  may 
simulate  a  carcinoma  most  closely,  especially  if  surrounded  by  chronic 
mastitis.  It  is  exceptional  to  obtain  fluctuation  in  a  deep  cyst.  The 
absence  of  enlarged  axillary  glands  and  of  adhesion  to  skin  or  fascia, 
while  suggesting  that  the  tumour  may  be  a  cyst,  does  not  exclude 
carcinoma.  It  is  true  that  the  puncture  of  the  tumour  by  a  trocar 
and  cannula  will  settle  whether  a  cyst  is  present ;  but  the  surgeon's 
anxiety  is  merely  transferred  from  the  tumour  to  the  surrounding 
breast  tissue,  since  a  carcinoma  not  infrequently  arises  in  the  breast 
tissue  near  a  cyst.  In  the  absence  of  unecjuivocal  signs  of  cancer, 
certainty  can  only  be  reached  by  exploration  and  histological 
examination. 


MAMMARY   CANCER:    DIAGNOSIS  77 

The  remarks  made  respecting  a  deep  cysl   apply  also  to  a  fibro- 
adenoma deeply  Bituated  and  Bnrrounded  by  an  area  of  chronic  m 
which   partially  fixes  it    in  the   breast.     The  diagnosis   from   cancer 
then  becomes  impossible,  and   exploration   is   imperative.    Sigi 
contraction  and  adhesion  are  absent.     Puncture  with  shows 

that   the  tumour  is  solid.     All  the  means  of  diagnosis,  Bave  actual 
exploration,  fail  to  exclude  carcinoma. 

Gummatous  and  tuberculous  must  1/ is.  which  in  their  early  stages 

Bimulate  ordinary  chronic  mastitis,  may  later  produce  one  or  more 
indurated  fixed  lumps  in  the  breast.  Adhesion  to  skin  and  fasci  1 
occur,  and  orange-rind  skin  may  be  present.  Moreover,  in  tubercle, 
and  even  sometimes  in  gummatous  mastitis,  the  axillary  glands  may 
be  enlarged,  hard,  and  not  tender.  At  this  period  the  resemblance 
to  carcinoma  is  very  (dose.  Usually,  however,  in  syphilis  a  careful 
search  will  detect  tertiary  lesions  other  than  those  in  the  breast,  and 
the  rapid  effect  of  treatment  with  iodide  will  clear  up  all  doubts. 
Tuberculosis  usually  occurs  in  younger  people  than  does  carcinoma, 
but  sometimes  the  diagnosis  is  impossible  before  operation.  In  the 
later  stages  of  both  gumma  and  tubercle  the  diagnostic  feature  is  a 
central  area  of  softening  in  the  midst  of  the  indurated  mass,  and  still 
later  the  discoloration  of  the  skin  which  heralds  the  bursting  of  an 
abscess. 

Fibrotic  changes  in  the  breast  resulting  from  a  former  abscess  may 
be  accompanied  by  some  of  the  signs  of  cancer,  and  especially  by 
adhesion  of  the  skin  and  shrinkage  of  the  affected  breast.  The  history 
of  suppuration,  the  presence  of  a  scar  upon  the  skin,  and  the  absence 
of  an  underlying  tumour  will  suffice  to  prevent  a  mistake. 

In  the  rare  cases  in  which  a  simple  tumour  of  the  breast  penetrates 
the  skin  (fungating  cystic  adenoma,  fungating  duct  papilloma),  malig- 
nant disease  is  closely  simulated.  Microscopical  examination  of  a 
large  piece  of  the  fungating  tissue  is  the  best  solution  of  the  difficulty. 
In  fungating  simple  tumours  it  may  be  possible  to  pass  a  probe  some 
distance  within  the  cystic  cavity. 

The  diagnosis  between  a  hard  cancer  and  a  sarcoma  is  easy,  owing 
to  the  absence  in  sarcoma  of  the  signs  dependent  upon  contraction, 
and  the  large  size,  softness,  and  rapid  growth  of  the  tumour.  But 
a  soft  cancer  and  a  sarcoma  may  be  quite  indistinguishable  save  on 
microscopical  examination.  In  sarcoma,  however,  the  axillary  glands 
are  only  exceptionally  infected. 

Prognosis. — The  prognosis  in  breast  cancer  is  difficult.  The 
questions  requiring  answer  are  mainly  two.  If  the  growth  runs  its 
natural  course,  how  long  has  the  patient  to  live  ?  After  operation, 
what  is  the  chance  that  the  growth  will  not  return  ? 

Upon  the  first  point  very  little  that  is  helpful  can  be  said,  and  the 


78  THE    BREAST 

widest  experience  is  liable  to  err.  If  the  growth  is  of  recent  and  rapid 
development,  and  the  patient  young,  life  will  probably  terminate 
within  a  few  months.  In  fibroid  cancers  of  slow  development  the 
expectation  of  life  is  two  to  four  years.  But  a  cancer  may  remain 
active  for  forty  years  without  killing  its  possessor,  as  in  a  case  which 
I  have  seen. 

A  prognosis  of  non-recurrence  after  operation  can  be  given  with 
fair  confidence  if  the  growth  has  not  acquired  adhesions  to  skin  or 
fascia,  nor  caused  axillary  enlargement,  always  provided  that  a  com- 
plete operation  is  performed.  These  are  the  cases  detected  by  ex- 
ploratory operation.  In  cases  where  diagnosis  is  possible  without 
exploration  the  chances  are  in  favour  of  recurrence,  and  it  is  best  to 
state  that  time  alone  will  settle  the  question.  In  cases  still  operable, 
but  presenting  advanced  symptoms,  such  as  ulceration,-  operation 
should  not  be  pressed,  and  the  probability  of  internal  recurrence 
should  be  mentioned.  But  apparently  advanced  cases  sometimes 
do  well,  and  in  cases  which  seem  early  some  disappointments  will 
nevertheless  occur. 

The  percentage  of  patients  who  are  permanently  cured  by  opera- 
tion has  steadily  increased  of  late  years  as  operative  methods  have 
improved.  Future  advances  depend  upon  the  earlier  recognition  of 
the  disease,  increasing  knowledge  of  its  pathology,  and  the  abandon- 
ment of  restricted  or  badly  planned  (though  extensive)  operations. 

Halsted's  results  show  that  when  the  modern  complete  operation 
is  performed  before  the  axillary  glands  have  become  involved,  two 
out  of  three  patients  are  permanently  cured  ;  while  when  the  axillary 
glands  are  already  infected  at  the  time  of  operation,  three  out  of  four 
patients  ultimately  die  of  their  disease.  Time  alone  can  show  the 
effect  of  recent  modifications  of  operative  methods. 

At  least  20  per  cent,  of  patients  who  survive  the  operation  three 
years  die  of  later  recurrencej 

Unusual  varieties  of  breast  cancer. — Breast  cancer 
is  so  variable  in  its  manifestations  that  it  is  impossible  to  furnish  a 
description  which  suits  all  cases.  Certain  special  forms  need  separate 
consideration. 

Medullary  or   soft  carcinoma The  hardness  of  a  typical 

scirrhus  is  due  to  the  fibrotic  processes  which  are  associated  with  it. 
If  the  proliferative  activity  of  the  cancerous  epithelium  outstrips 
these  defensive  fibrotic  processes,  a  large  lobulated  growth  of  relatively 
soft  consistence  is  rapidly  formed.  The  axillary  glands  become 
enlarged  and  may  soon  attain  the  size  of  chestnuts,  and  the  skin 
becomes  extensively  adherent  and  assumes  the  orange-rind  appearance. 
Ulceration  supervenes,  and  a  fungating  mass  of  malignant  tissue 
protrudes,  from  which  large  sloughs  may  separate.     Sepsis,  repeated 


VARIETIES   OF    MAMMARY   CANCER 

bleeding,  and  dissemination  lead  rapidly  to  death.  T"  growtl 
this  character  the  name  medullary  carcinoma  was  formerly  applied, 
as  indicating  their  soft,  marrowy  consistence.  They  occur  more 
especially  in  young  women,  and  arc  of  bad  prognosis.  Marry  <>f 
the  cases  which  clinically  present  the  features  to  be  described  ae 
characteristic  of  sarcoma  are  nevertheless  found  mi  microscopical 
examination  to  be  carcinomas  of  this  type. 

Atrophic    scirrhus. — Cases    are   not    uncommon    in    which   the 

Btruggle     between    the    cancel'    and     the    individual     is    prolonged     and 

doubtful.  Such  appears  to  be  t  he  t  rue  explanaf  inn  of  cases  (,t  ;(t  rophic 
scirrhus.  In  the  most  marked  form  of  atrophic  scirrhuB  a  puckered 
scar,  to  which  the  skin  may  lie  attached,  slowly  forms  in  the  breast. 
The  whole  breast  becomes  somewdiat  shrunken  and  the  nipple  indrawn, 
but  no  definite  tumour  makes  its  appearance. 

The  disease  in  this  form  is  usually  painless,  and  the  patient's 
attention  is  attracted  only  by  local  puckering  and  adhesion  of  the 
skin.  Frequently  the  patient  attaches  no  importance  to  these  signs, 
and  it  is  only  when  she  consults  a  medical  man  for  some  other  con- 
dition that  the  lesion  of  the  breast  is  discovered.  The  condition  may 
persist  for  many  years  without  obvious  change  until  the  patient  dies 
of  some  other  disease,  but  if  she  survives  long  enough  it  is  likely  that 
local  malignant  ulceration  or  dissemination  resulting  from  permeation 
will  terminate  the  case. 

In  less  extreme  cases  of  atrophic  scirrhus  the  primary  focus,  after 
attaining  the  dimensions  of  a  definite  tumour,  subsequently  shrinks 
and  disappears,  or  leaves  only  a  mass  of  dense  fibrous  tissue,  in  the 
central  portion  of  which  no  trace  of  malignant  epithelium  can  be  found. 
The  breast  is  reduced  to  a  small  fibrous  relic  resembling  the  male 
breast.  Complete  fibrosis  of  the  primary  growth  does  not  necessarily 
or  usually  prevent  dissemination,  which,  however,  in  these  cases  is 
very  slow,  attacking  rather  the  skin,  subcutaneous  tissue,  and  bones 
than  the  internal  organs. 

Some  authorities  state  that  cases  of  atrophic  scirrhus  should  not 
be  operated  upon — an  opinion  which  probably  dates  from  the  time 
when  nearly  every  operation  upon  breast  cancer  was  an  incomplete 
one.  If  any  part  of  the  growth  is  left  behind,  it  is  quite  likely  that 
it  may  be  stimulated  to  vigorous  activity  by  the  operative  interference. 
But  there  is  now  a  reasonable  hope  of  complete  operative  eradication 
of  the  disease,  and,  even  if  this  end  is  not  attained,  the  inhibitory 
action  of  X-rays  may  be  called  in  to  assist  the  effect  of  the  operation. 
I  hold,  therefore,  that  cases  of  atrophic  scirrhus.  except  in  very  old 
or  very  feeble  patients,  should  be  operated  upon.  No  one  can  tell 
when  an  atrophic  scirrhus  may  blossom  forth  into  a  carcinoma  with 
active  powers  of  dissemination. 


8o  THE    BREAST 

In  deciding  whether  to  operate  upon  an  atrophic  Bcirrhus  an 
especially  careful  general  examination  must  be  made,  for  the  growth 
may  have  been  present  for  years  and  dissemination  may  have  made 
progress  before  the  mammary  signs  led  the  patient  to  seek  advice. 
Sometimes  a  spontaneous  fracture  of  the  femur,  a  deposit  in  the  spine, 
or  the  presence  of  an  abdominal,  pelvic,  or  hepatic  tumour  may  be 
the  first  obvious  sign  of  an  atrophic  carcinoma  of  the  breast,  or  of  a 
tumour  of  some  size  embedded  in  a' voluminous  mamma.  If  a  tumour 
is  detected  in  a  woman  of  middle  age,  whatever  its  situation,  the 
breasts  must  be  carefully  examined  for  signs  of  carcinoma. 

Peripheral  carcinoma — A  carcinoma  of  the  breast  may 
commence  in  some  outlying  lobule  apparently  quite  separate  from 
the  main  body  of  the  gland.  The  possibility  that  these  outlving 
growths  may  begin  in  a  supernumerary  mamma  must  not  be  over- 
looked. 

The  prognosis  of  peripheral  carcinoma  is  worse  than  that  of  the 
more  central  variety.  A  peripheral  growth  is  likely  to  be  separated 
from  the  pleural  cavity  by  a  relatively  thin  protective  layer  of  muscles, 
as  compared,  for  instance,  with  a  growth  which  overlies  the  great 
pectoral.  Consequently  the  growth  early  becomes  adherent  to  the 
chest  wall,  and  therefore  inoperable.  Moreover,  operations  for  peri- 
pheral carcinoma  in  the  past  have  nearly  always  violated  the  rule, 
deduced  by  the  writer  from  the  permeation  theory,  that  the  primary 
growth  must  form  the  centre  of  the  field  of  operation  and  of  the 
area  of  tissue  removed.  The  observance  of  this  rule  is  of  cardinal 
importance  in  these  outlying  growths. 

The  case  of  peripheral  scirrhus  represented  in  Fig.  279  was  that  of  a 
female  aged  about  65.  Situated  accurately  in  the  middle  line,  just  above 
the  ensiform  cartilage,  at  the  point  to  which  the  lower  contours  of  the 
mammae  converge,  was  an  irregular  ulcer,  about  an  inch  in  average  diameter, 
with  a  sloughy  base,  and  hard,  irregular,  raised  edges  surrounded  by  sub- 
cutaneous induration.  The  whole  mass,  which  could  be  covered  by  a  florin, 
was  firmly  adherent  to  the  underlying  sternum,  which,  however,  was  not 
exposed  in  the  floor  of  the  ulcer.  The  situation  of  the  lesion  suggested  a 
gumma.  This,  however,  was  excluded  by  the  absence  of  suppuration,  by 
the  fact  that  bone  was  not  exposed,  by  the  absence  of  a  syphilitic  history, 
and  above  all  by  the  presence  in  both  axillae  of  hard  enlarged  glands  of  the 
.type  familiar  in  carcinoma.  The  median  situation  of  the  growth  had  led 
to  simultaneous  invasion  of  the  axillary  glands  on  both  sides. 

Acute  cancer  of  the  breast  (mastitis  carcinomatosa,  brawny 
cancer).  —  The  most  acute  form  of  breast  cancer  is  found  only  in 
women  below  middle  age,  and  usually  of  florid  aspect.  It  is  accom- 
panied by  an  erythematous  blush  of  the  skin  over  the  tumour.  It 
generally  develops  during  lactation,  though  it  may  also  occur  in 
virgins.     All  the  signs  of  inflammation  are  present.     The  whole  breast 


ACUTE   MAMMARY   C  wci.K 

is  Bwollen  and  prominent.    The  skin   is  red  and  hot,  and  may  be 
swollen    and    oedematous,    Bometimes    presenting    the    typioal 

d'orang*   appearance.     The  nipple  may  I ither  retracted,  or  swollen 

mil  oedematous.     A  large  tumour  rapidly  involves  the  entire  b 
mil  becomes  firmly  fixed  to  .-kin  and  fascia.     Within  a  few  weeks  the 


Fig.  279. — Ulcerated  scirrhous  carcinoma  situated  in  the  angle 
between  the  two  breasts,   in  the  middle  line. 

chest  wall  may  present  the  appearance  of  advanced  cancer  en  cuirasse. 
The  thickened  and  rigid  skin,  now  immobile  upon  the  chest  wall,  is 
covered  with  cancerous  bosses.  General  dissemination  rapidly  takes 
place,  and  within  a  period  of  from  six  weeks  to  three  months  after 
the  onset  of  the  disease  the  patient  is  dead.  Operation  in  these 
cases  is  useless.  The  cutaneous  oedema  may  lead  to  the  erroneous 
diagnosis  of  mastitis  or  mammary  abscess. 
g 


S2 


THE   BREAST 


In  some  cases  of  acute  cancer,  swollen  white  cords,  radiating  from 
the  nipple,  may  be  seen  upon  the  surface  of  the  skin.  It  is  usually 
believed  that  they  are  the  larger  superficial  lymphatics  distended 
by  lymph.     The  intermediate  skin  is  swollen  from  lymphatic  oedema. 

Diagnosis. — Not  infrequently  acute  cancer  of  the  breast  has  been 
mistaken   for  mammary   abscess,    and   has   been   incised   under   this 


♦    -     -    'Vv 


• 


^V; 


■a 


;. 


Fig.  280. — Edge  of  an  actively  infiltrating  cancer  of  the  breast 
under  a  low  magnification  (  x  5).  Note  the  narrow  dark 
columns  of  cancer  cells  penetrating  the  interstices  of  the 
surrounding  tissues.     Cf.  Fig.  281. 


impression.  Although  oedema  of  the  skin  may  be  present  over  a 
pointing  abscess,  it  is  rarely  extensive.  In  acute  cancer  the  lymphatic 
oedema  of  the  skin  is  coextensive  with  the  breast,  and,  moreover, 
the  affected  area  is  uniformly  and  firmly  adherent  to  the  underlying 
breast,  and  often  indurated  from  commencing  cancerous  infiltration. 
The  breast,  too,  is  firmly  fixed  to  the  chest  wall,  which  is  not  the 
case  in  acute  mastitis. 

Impalpable  carcinoma  of  the  breast. — It  is  an  important  fact 
that  in  rare  cases  a  carcinoma  may  be  present  in  the  breast  for  a  long 


DUCT   CANCER 

period,  and  even  for  many  years,  withoul  giving  rise  to  any  pali 
tumour.    Sometimes  in  these  cases  enlargement  oi  the  axillary  glands 
and  the  later  signs  oi  dissemination  remain  absent,  and  thi 
tion      .1  r [-■>]'  1  ii>    scin-lius  "  is  appropriate  <<••  p.  79).     In  othei  ■ 
however,   though   the  primary  growth  remains   ol   microscopic   aize, 
enlargement  <>f  the  axillary  glands  occurs,  and  the  glands  may  even 
reach  the  size  of  chestnuts.    Tin'-''  cases  were  formerly  describi 
primary  cancer  of  the  axillary  glands.     In  such  cases,  it  the  glands  are 


I 


:% 

Fig.  281. — The  edge  of  a  mobile  (non-infiltrating)  carcinoma  of  the 
breast  under  a  low  magnification  (  x  5).  The  growth  was  sur- 
rounded by  a  capsule  of  fibrous  tissue  almost  as  definite  as  that 
of  a  fibro-adenoma.     Cf.  Fig.  280. 

cancerous  and  no  other  primary  focus  can  be  found,  the  breast  should 
be  removed,  and,  as  in  a  case  of  which  Dr.  Macnaughton  Jones 
informs  me,  thorough  microscopical  examination  may  reveal  a  minute 
mammary  carcinoma.  Halsted  has  met  with  two  similar  cases.  The 
facts  of  impalpable  carcinoma  have  an  important  bearing  upon  the 
pathology  of  Paget's  disease  of  the  nipple  {see  p.  10). 

In  certain  cases  which  simulate  impalpable  carcinoma,  a  primary 
growth  originating  at  the  axillary  edge  of  the  breast  may  be  mistaken 
for  an  enlarged  axillary  gland. 

Mobile  carcinoma  of  the  breast. — It  is  too  often  assumed  that 
a  carcinoma  of  the  breast  is  always  firmly  fixed  in  the  organ.     This 


84  THE   BREAST 

is  indeed  the  case  if  the  growth  is  an  actively  infiltrating  one.  But 
certain  exceptional  carcinomas  of  the  ordinary  spheroidal  type  are 
sluggish  in  this  respect,  and  they  consequently  acquire  a  fibrous  <  ;ipsule, 
sometimes  almost  as  definite  as  that  of  a  fibro-adenoma.  The  capsule 
may  be  complete,  even  upon  histological  examination  (Fig.  281),  and 
in  such  cases  the  tumour  is  mobile  and  may  even  be  enucleated 
without  much  difficulty.  Thus,  after  removal  of  the  tumour,  and  still 
more  easily  before  operation,  it  may  be  mistaken  for  a  fibro-adenoma. 
An  apparent  fibro-adenoma  first  appearing  after  the  age  of  40  is 
more  likely  than  not  to  be  a  carcinoma. 

Although  these  cases  are  exceptional,  they  lead  to  conclusions  of 
the  greatest  importance  :  (1)  In  women  approaching  the  canceriage, 
all  rounded  tumours  of  the  breast,  even  those  which  appear  quite 
innocent,  should  be  dealt  with  promptly  by  operation.  (2)  All  tumours 
of  the  breast  after  removal  must  be  submitted  to  microscopical 
examination. 

Duct  cancer  of  the  breast  (columnar -celled  carcinoma). — 
Histologically  this  disease  is  divisible  into  two  forms — (1)  carcinoma 
originating  in  the  large  ducts  ;  (2)  carcinoma  beginning  in  the  small 
ducts.  In  the  former  variety  (Fig.  283)  the  breast  is  riddled  with  caseous 
areas  which  are  the  greatly  dilated  ducts  filled  with  the  caseous  debris 
of  cancerous  epithelium,  or  with  richly  plicated  papillomatous  out- 
growths, or  with  hemorrhagic  debris.  Outside  these  spaces  there  is 
irregular  cancerous  infiltration  of  the  tissue  spaces  of  the  breast.  Such 
cases  appear  to  originate  as  innocent  duct  papillomas  which  have 
undergone  malignant  degeneration  (Fig.  282).  The  growths  are  of 
slow  development  and  of  relatively  good  prognosis.  They  are  slow 
in  becoming  adherent  to  their  surroundings  and  in  affecting  the 
axillary  glands.  They  develop  usually  beneath  the  nipple,  and  in 
women  over  middle  age.     Retraction  of  the  nipple  is  usually  absent. 

The  other  variety  of  duct  carcinoma — that  originating  in  the 
small  ducts — has  not  yet  been  clinically  differentiated  from  the 
ordinary  spheroidal-celled  or  acinous  carcinoma.  The  histological 
picture  is  that  of  small,  irregularly  proliferating  spaces  lined  with 
columnar  cells.  These  spaces  infiltrate  the  breast  tissue  and  convert 
the  regular  pattern  of  its  lobular  structure  into  a  confused  and  irre- 
gular maze.  The  picture  presented  recalls  that  of  a  columnar-celled 
adeno-carcinoma  of  the  intestine  (Fig.  271). 

Xot  infrequently  this  variety  of  duct  cancer  is  accompanied  by 
cancerous  changes  in  the  acini  also,  and  it  may  be  difficult  to  say 
whether  the  growth  is  a  columnar-  or  a  spheroidal-celled  carcinoma. 

Clinical  history. — In  cases  of  carcinoma  of  the  breast,  if  there  is 
a  historv  of  serous  discharge  from  the  nipple  of  some  years'  standing, 
the  disease  will  almost  certainly  prove  to  be  a  duct  cancer ;  if  Paget's 


<:  WCKR  of  THE   MALE    BRE  \si 


disease  of  the  nipple  has  been  present,  il  is  no1  unlikely  thai  the  d 
may  be  of  the  columnar-celled  variety.  Bu1  the  distinction  \«  ■ 
Columnar*  and  Bpheroidal-celled  canoer  is   nol    one  ol   greal    clinical 

importance,  since  in  cither  case  the  treatmenl    is  the  same.     It    is, 
however,  essential  to  recognize  clearly  thai   the  absence  of  rig 
contraction  and  adhesion  is  not   inconsistenl   with  the  presence  ot  a 
carcinoma  of  t  he  duel  variety. 

Carcinoma  of  the  male  breast — The  male  breasl  is  liable  to 
most  of  the  diseases  which  alYect  the  female  breast.  Chronic  mastitis, 
adenoma,  sarcoma,  duct,  papilloma,  and  other  conditions  occur  as 
rarit  ies  in  the  male.  But  the  only  disease  whose  comparative  frequency 
gives  it  importance  is  carcinoma,  which  may  be  of  the  spheroidal- 
or  the  columnar-  or  the  squamous-celled  variety.  The  disease  appears 
later  in  men  than  in  women,  and  in  nine  cases  collected    by  ('.  \l.  Kevser 


Fig.  282. — Cystic  duct  papilloma  passing  into  duct  carcinoma. 
The  papillomatous  growths  beneath  the  nipple  are  com- 
mencing to  infiltrate  the  surrounding  tissues. 

{From  a  case  under  the  writer's  care.       The  specimen  is  preserved  in  the  Middlesex 

Hospital  Museum.) 

the  average  age  was  61  years.  J.  R.  Lunn  has  recorded  a  case  of 
duct  cancer  in  a  man  of  91,  and  this  appears  to  be  the  oldest  age  on 
record  in  this  connexion.  Of  100  breast  cancers,  only  one  occurs  in 
a  male.  ^  history  of  definite  injury  is  common,  The  disease  begins 
as  a  button-like  induration,  at  first  mobile,  situated  beneath  or  near 
the  nipple.  Later,  adhesion  to  skin  or  fascia  develops,  the  axillary 
glands  become  enlarged,  and,  by  the  time  the  growth  has  reached  the 
size  of  a  walnut,  ulceration  sets  in.  In  more  than  half  the  cases 
the  tumour  is  ulcerated  when  the  surgeon  first  sees  it.  This  may  be 
accounted  for  by  the  absence  of  pain  prior  to  ulceration,  and  the 
freedom  of  men  from  dread  of  this  particular  disease. 

In  all  its  essential  features,  cancer  of  the  male  breast  is  identical 
with  the  same  disease  in  the  female.  It  requires  treatment  on  the 
same  lines  and  by  an  equally  free  operation.  There  can  be 
little  doubt,  however,  that  operations  for  cancer   of  the  male  breast 


86 


THE    BREAST 


have    been   unduly    restricted,  the   small  size   of   tlie  breast    and  of 
the  primaiy  lesion  seeming  to  invite  a  limited  excision. 

Exploratory  in- 
cision prior  to 
operation.  —  Some 
surgeons  believe  it  to 
be  dangerous  to  incise  a 
doubtful  carcinoma  be- 
fore removing  it,  on  ac- 
count of  the  danger  of 
liberating  cancer  cells 
which  may  become  im- 
planted upon  the  field 
of  operation.  The  risk 
is  a  very  small  one  if 
precautions  are  taken  ; 
but,  of  course,  a  carcino- 
ma should  not  be  incised 
if  the  diagnosis  is  certain. 
In  case  of  doubt  a  small 
incision  is  made  down 
upon  the  growth  and  its 
enucleation  is  attempted. 
If  the  effort  is  unsuccess- 
ful an  incision  is  made 
into,  but  not  through, 
the  central  portion  of  the  growth.  If,  after  inspection,  or  removal 
of  a  small  piece,  malignancy  is  diagnosed,  the  wound  is  stuffed  with 
a  small  swab,  the  deeper  portion  of  which  has  been  dipped  in  pure 
phenol,  and  the  small  wound  is  tightly  sewn  up  over  the  swab.  The 
instruments,  towels,  swabs,  and  gloves  so  far  used  are  discarded,  and 
the  operation  for  carcinoma  is  begun. 

Naked-eye  characters  of  an  incised  carcinoma. — 
The  tumour  may  creak  under  the  knife,  but  more  commonly  cuts 
like  a  piece  of  potato.  It  cannot  be  shelled  out  of  its  bed,  save  in 
rare  instances,  and  it  exhibits  radiating  fibrous  processes  firmly 
anchored  amid  the  surrounding  fat.  In  colour  it  is  greyish  or  pinkish- 
grey,  in  this  respect  and  in  its  consistency  contrasting  with  the  leathery 
toughness  and  yellowish  tinge  of  chronic  mastitis,  and  with  the  whitish 
enucleable  fibro-adenoma.  Upon  the  greyish  surface  of  a  carcinoma, 
yellow  clots  representing  areas  of  necrosis  are  frequently  visible.  An 
opaque  fluid  (cancer  juice)  can  be  scraped  from  the  cut  surface,  which 
becomes  characteristically  concave  as  soon  as  the  section  is 
made. 


Fig.  283. — Duct  papilloma  and  duct  car- 
cinoma in  the  same  microscopic  field. 
A  large  duct  crosses  the  field  vertically. 
From  its  right  wall  a  small  duct  papil- 
loma projects  into  the  lumen.  From 
its  left  wall  is  seen  an  outgrowth  of 
columnar-celled  carcinoma  which  is  in- 
filtrating the  surrounding  tissues,   x  20. 


OPERATION    FOR   MAMMARY  GANGER 

Rapid  microscopical  examination.  II  naked-eye  inspec- 
tion does  ii"'  resolve  doubts  as  to  the  nature  ol  the  tumour,  il 
think,  bettei  i-  a  general  rule  to  se^  up  the  wound  and  defci  the 
operation  for  .1  fe^  days  until  a  paraffin  section  oi  the  excised  piece 
has  been  made.  Bui  if  a  skilled  pathologist  1-  available  an  immediate 
examination  Bhould  be  made  in  the  theatre  by  one  "I  the  rapid  freezing 
methods,  perhaps  the  besl  of  which  is  Leitch's.  The  method  is  not 
to  be  relied  upon  unless  tin-  observer  lias  had  long  practice  in  the 
examination  of  frozen  sections  a  Eacj  acknowledged  by  it.-  pioneer, 
Ernest  \\.  Shaw.  Few  pathologists  possess  the  necessary  experience, 
and  for  this  reason  the  method,  though  ideal,  is  al  presenl  not 
generally  applicable. 

Principles  of  the  operation  for  breast  cancer.  While 
many  technical  variations  are  possible  in  the  operation  for  breast 
cancer,  especially  as  regards  the  planning  of  the  skin  incision,  certain 
general  principles  determined  by  the  mode  of  spread  of  the  disease 
must  be  held  inviolable.  The  aim  of  the  operation  is  not  merely  to 
"amputate  the  breast."'  though  this  is  in  all  cases  necessary,  but 
to  remove  intact  the  'permeated  area  of'  the  lymph-vascular  system  ivhich 
sun-minds  the  primary  growth,  in  one  piece  with  the  lymphatic  glands 
which  ■may  have  been  embolically  invaded  along  the  trunk  lymphatics 
of  the  permeated  area.  To  attain  this  object  certain  points  must  be 
specially  borne  in  mind. 

1.  The  area  of  the  operation  must  be  concentric  with  the  growth. 
Only  when  the  growth  itself  is  central  must  the  nipple  be  taken  as 
the  central  point  of  the  area  of  skin  and  subjacent  tissue  to  be 
ablated. 

2.  The  area  of  tissue  removed  must  approximate  to  a  circle  in 
shape,  in  view  of  the  centrifugal  spread  of  permeation. 

3.  Since  permeation  spreads  primarily  by  way  of  the  deep  fascial 
lymphatic  plexus,  the  ablation  of  tissue  must  be  most  extensive  in 
the  plane  of  the  deep  fascia,  and  the  area  of  fascia  removed  must 
be  a  circle. 

4.  Smaller  circular  areas  of  skin  and  of  muscle  also  require  re- 
moval, on  account  of  the  secondary  invasion  of  these  layers  from 
the  permeated  fascial  plexus. 

5.  The  skin  incision,  subject  to  the  preceding  condition,  should 
afford  convenient  access,  and  should  not  be  so  placed  that  the  scar 
will  be  along  the  anterior  axillary  fold,  since  in  this  situation  it  will 
tend  to  bind  the  arm  to  the  side. 

It  may  here  be  repeated  that  the  very  extensive  ablation  of  skin 
carried  out  by  some  surgeons,  based  upon  erroneous  ideas  concerning 
dissemination,  is  not  found  in  practice  to  improve  the  results  of  the 
operation. 


88  THE    BREAST 

6.  During  the  operation,  precautions  should  be  taken  against  the 
possibility  of  epigastric  invasion  of  the  abdomen. 

Choice  of  cases  for  operation. — Now  that  the  immediate 
risk  of  operation  is  under  2  per  cent.,  it  is  unfair  to  refuse  operation 
unless  the  case  is  evidently  hopeless.  Apparently  advanced  cases 
sometimes  do  well,  and,  even  if  internal  recurrence  takes  place,  the 
patient  may  be  saved  the  distress  of  an  ulcerated  growth.  In  early 
cases  operation  should  be  urged,  in  later  cases  offered. 

Except  in  rare  instances  as  a  palliative  measure  for  the  removal 
of  a  foul  ulcerated  mass,  operation  should  be  refused — 

(a)  When  the  primary  growth  has  become  attached  to  the  bony 

thorax. 

(b)  In  the  presence  of  cancer  en  cuirasse,  or  of  subcutaneous 

nodules  or  skin  infiltration  situated  more  than  2_Jn.  from 
the  primary  growth. 

(c)  If  there  is  a  fixed  mass  of  growth  in  the    axilla,  evidently 

adherent  to  its  walls. 

(d)  If  there  is  marked  oedema  of  the  arm. 

(e)  If  the  supraclavicular  glands  are  enlarged,  hard,  and  fixed. 
(/)  If  there  is  evidence  of  visceral  or  bone  metastases. 

(g)  If  there  is  incurable  constitutional  disease — tuberculosis  or 
diabetes,  for  example — likely  to  be  fatal  in   a  few  years 
at  most,  or  to  lead  to  a  postoperative  fatality. 
(h)  In  the  acute  forms  of  carcinoma. 

Examination  prior  to  operation. — Remember  to  examine 
the  spine  for  angular  curvature,  the  epigastric  parietes  for  nodules, 
and  the  pelvis  for  deposits  in  the  ovaries  and  in  Douglas's  pouch, 
in  addition  to  the  usual  preoperative  medical  examination. 

Preparation  of  the  patient.  —  Since  massage  of  the 
mammary  region  must  tend  to  favour  dissemination,  no  compress 
should  be  employed.  The  axilla  should  be  dry-shaved  overnight, 
and  the  whole  field  painted  with  iodine  a  few  hours  before  operation, 
and  again  upon  the  table. 

During  the  operation  the  arm  must  not  be  forcibly  stretched 
upwards  so  as  to  injure  the  brachial  plexus.  The  whole  operative 
field  must,  as  far  as  is  possible,  be  covered  up  with  relays  of  hot  towels. 
The  best  anaesthetic  is  C.E  mixture,  accompanied  by  a  feeble  stream 
of  oxygen.  Pure  ether  is  inadvisable  because  by  inducing  very  free 
hsernorrhage  it  may  be  the  indirect  cause  of  postoperative  shock. 

Technique  of  the  operation  (Handley  s  method). — 
The  skin  incision  is  only  just  deep  enough  to  open  up  the  subcu- 
taneous fat  without  extending  through  it  into  the  neighbourhood  of 
the  deep  fascia.     It  consists  of  three  parts  : — 

1.  A  ring  incision,  as  first  practised  by  Mitchell  Banks,  4  to  5  in. 


OPERATION    FOR    MAMMARY   CANCER 


in  diameter,  accurately  centred  on  the  growth  and  surrounding  it 
.it  a  safe  distance,  slightly  tailing  ofi  into  incision  No.  2  ibove,  and 
into  Ni>.  •"»  belov . 

2.  A  curvilinear  incision  Eor  giving  access  to  the  axilla.  The  axilla 
is  opened  by  turning  forward  a  flap,  consisting  of  skin  and  a  thin  layer 
of  subcutaneous  Eat,  whose  base  lies  along  the  anterior  aadllax] 

The  axillary  incision  begins  at  the  lower  edge  of  the  great  pectoral, 
close  to  its  insertion. 
It  ends,  also  at  the 
lower  edge  of  the 
great  pectoral,  by  join- 
ing the  annular  inci- 
sion. No.  1.  It  (losses 
the  base  of  the  axilla. 
and  marks  out  a 
shallow  semilunar  flap 
of  skin,  whose  con- 
vexity lies  in  the 
vault  of  the  axilla  not 
far  from  the  edge  of 
the  latissimus  dorsi. 
It  affords  perfect  ac- 
cess to  the  axilla,  and 
good  drainage  after- 
wards. 

3.  A  linear  inci- 
sion coming  off  from 
the  lower  and  inner 
part  of  the  annular 
incision  and  passing 
downwards  for  about 
2  in.  along  the  linea 
alba.     Its  object  is  to 

give  access  for  the  removal  of  the  deep  fascia  over  the  upper  part 
of  the  abdominal  wall.  "Without  it  this  important  step  in  the 
operation  cannot  be  properly  carried  out. 

Elevation  of  the  skin  flaps. — The  skin  flaps  are  next  under- 
mined in  the  mid-plane  of  the  subcutaneous  fat  until  there  is  exi 
an  area  of  the  deeper  subcutaneous  fat,  forming  a  circle  10  to 
12  in.  in  diameter,  with  the  primary  growth  at  its  centre.  The 
exact  anatomical  limits  of  this  dissection  will,  of  course,  vary  with 
the  situation  of  the  growth  in  the  breast.  The  assistant  retracts 
the  skin  flaps  as  they  are  formed,  and  subsequently  keeps  them 
carefully    wrapped    in    hot    towels    frequently   renewed.     N 


Fig.  28-4. — Recurrence  of  breast  carcinoma 
following  an  inadequate  operation.  A 
portion  only  of  the  breast  has  been 
removed,  and  the  axilla  has  not  been 
cleared.  Recurrence  has  taken  place 
in  the  subclavian  glands,  and  a  mass  of 
growth  is  seen  pushing  the  pectorals 
forward. 


9o  THE    BREAST 

this  precaution  is  likely  to  be  followed  by  ulceration  of  the  edges 
of  the  flaps. 

A.1  tin-  period  of  the  operation  no  attempt  should  be  made  to  apply 
artery  forceps  to  every  small  bleeding-point.  Spouting  vessels  in 
the  deep  surface  of  the  skin  flap  should  be  clamped,  but  bleeding 
from  the  exposed  surface  of  subcutaneous  fat  is  sufficiently  checked 
by  the  pressure  of  large  flat  swabs,  for  nearly  all  the  exposed  vessels 
will  again  be  divided  at  a  deeper  level. 

Delimitation  of  the  area  of  deep  fascia  to  be  removed. 
— An  annular  incision,  marking  out  the  10-in.  circle  of  deep  fascia 
to  be  removed,  is  now  carried  down  to  the  muscles  through  the  deeper 
subcutaneous  fat  close  to  the  base  of  the  skin  flaps,  which  are  mean- 
while  strongly  retracted  by  the  assistant. 

Elevation  of  deep  fascia  from  the  underlying  muscles. 
— The  circular  area  of  deeper  subcutaneous  fat  and  deep  fascia,  in 
which  lies  embedded  the  presumably  permeated  area  of  the  fascial 
lymphatic  plexus,  is  now  dissected  from  the  subjacent  muscles  for 
some  distance  from  its  circumference  towards  its  centre,  so  as  to  form 
a  wide  marginal  fringe  of  the  main  mass,  consisting  of  breast,  pectoral 
muscles,  and  axillary  contents,  which  is  to  be  subsequently  removed. 
The  fringe  of  deep  fascia  is  to  be  raised  up  all  round  the  field  of 
operation  until  the  knife  reaches  either  the  margin  of  the  great  pectoral 
muscle,  the  margin  of  the  axillary  outlet,  or  the  edge  of  the  breast, 
as  the  cast:-  may  be. 

The  amount  of  dissection  required  varies  in  different  parts  of  the 
field  of  operation.  At  the  upper  limit  of  the  field  of  operation  hardly 
anv  freeing  of  the  fascia  will  be  required,  since  in  this  region  it  will 
come  away  with  the  great  pectoral  when  that  muscle  is  divided  below 
its  clavicular  origin.  Towards  the  middle  line  the  fascia  will  usually 
require  dissecting  up  from  the  inner  margin  of  the  opposite  great 
pectoral  and  from  the  sternum.  In  doing  this  the  perforating  branches 
of  the  internal  mammary  artery  on  the  side  opposite  to  the  growth 
are  often  divided,  and  must  be  secured.  The  division  of  these  branches 
jsarily  implies  also  division  of  the  lymphatics  which  run  with 
them  from  the  pectoral  lymphatic  plexus  to  the  anterior  mediastinal 
glands,  and  thus  additional  security  against  thoracic  invasion  is 
obtained.  (The  corresponding  perforating  branches  on  the  same  side 
as  the  growth  are  divided  later  during  the  detachment  of  the  great 
pectoral.) 

As  regards  the  lower  limit  of  the  field  of  operation,  it  will  be  found 
that  a  10-in.  circle  of  deep  fascia  with  the  growth  at  its  centre  will 
usually  extend  well  down  over  the  epigastric  region  of  the  abdomen. 
In  this  part  of  the  field  of  operation  the  anterior  layer  of  the  rectus 
sheath  on  both  sides  of    the  middle  line  should  be  raised  up,  and 


OPERATION    FOR    MAMMARY   GANGER  - 

removed  with  the  deep  fascia.  In  order  to  acoomplish  this,  the  linea 
alba  musl  be  splil  from  belo*  upwards  in  the  corona]  plane.  Ii  i- 
particularly  in  the  epigastric  region  thai  wide  and  careful  removal 
of  the  deep  Eascia  is  mosl  imperatively  called  for,  so  ae  to  prevenl 
the  access  of  cancer  cells  to  the  peritonea]  cavity.     In  this  pari   ol 

fche  field  ol  operation  numerous  small  bl L-vessels  emerging  from  the 

rectus  muscle  will  probably  need  attention. 

Towards  the  outer  side  of  the  field  of  operation  the  Eascia  musl 
be  dissected  up  from  over  the  anterior  edge  of  the  latissimus  and  from 
the  serratus  magnus.  Higher  up,  especially  if  the  growth  lies  in  the 
outer  portion  of  the  breast,  the  fascia  over  the  inner  margin  of  the 
deltoid  muscle  and  about  the  posterior  margin  of  the  axillary  outlel 
musl  be  raised  if  it  falls  within  the  circle  marked  out  for  removal, 
although  the  requisite  dissection  is  difficult  and  tedious. 

Division  of  muscles. — If  the  growth  is  an  early or  is  situ- 
ated low  down  in  the  breast,  it  is  probably  safe  to  leave  the  uppermost 
fibres  of  the  pectoralis  major  near  the  margin  of  the  deltoid  muscle. 
With  this  exception  the  whole  of  the  great  pectoral  needs  removal, 
as  Halsted  first  pointed  out.  It  is  split  below  its  clavicular  attach- 
ment; next,  a  finger  is  inserted  beneath  the  muscle  from  above, 
so  as  to  put  its  fibres  on  the  stretch,  and  its  chondral  and  sternal 
attachments  are  rapidly  divided  from  above  downwards  close  to 
their  origin.  The  muscle  is  lifted  from  the  chest  and  turned  out- 
wards, and  the  external  anterior  thoracic  nerve  and  the  vessels 
which  run  with  it  are  divided  where  they  pierce  the  costo-coracoid 
membrane. 

The  pectoralis  minor  now  comes  into  view,  and  is  best  removed, 
except  in  early  cases.     It  is  divided  at  its  costal  origin. 

The  pectoral  muscles  are  now  cut  across  at  their  insertions  respec- 
tively into  the  humerus  and  the  coracoid  process,  and  the  whole  mass 
of  tissue  is  allowed  to  fall  over  towards  the  axilla. 

Removal  of  axillary  contents. — The  costo-coracoid  membrane, 
now  freely  exposed,  is  cautiously  divided  just  below  the  clavicle,  and 
the  fat  at  the  extreme  apex  of  the  axilla  is  thus  brought  into  view. 
It  now  becomes  easy  to  reach  the  highest  axillary  glands — subclavian 
in  the  strict  sense  of  the  word — which  so  easily  escape  notice  unless 
they  are  carefully  looked  for.  The  axillary  vein  is  sought  for  in  this 
situation,  and  is  carefully  cleared  from  above  downwards.  As  this 
dissection  proceeds,  the  subscapular  vein  and  other  axillary  tributaries 
come  into  view,  and  are  secured  and  divided.  The  subscapular  nerve- 
are  exposed,  isolated,  and  preserved.  The  inner  and  posterior  walls  of 
the  axilla  are  cleaned  from  above  downwards,  preserving  the  nerve  of 
Bell,  and  the  mass  of  tissues  is  now  retained  only  where  the  lower  and 
outer  part  of  the  breast  overlies  the  serratus  magnus.     The  dictations 


92  THE   BREAST 

of  this  muscle,  which  lie  in  direct  contact  with  the  deep  surface 
of  the  breast,  should  be  divided  at  their  origin  from  the  ribs.  The 
whole  mass  of  tissues  is  now  freed  and  removed  by  the  division,  farther 
back  towards  the  scapula,  of  these  same  digitations  of  the  serr.it us 
maguus.  A  superficial  layer  of  the  digitations  of  the  external  oblique, 
which  arise  from  the  fifth  and  sixth  ribs,  should  also  be  removed. 

The  parts  removed  form  a  single  circular  biconvex-lens-like  mass 
with  thin  extensive  fascial  edges.  To  its  outer  side  a  pyramidal  mass 
of  axillary  fat  and  glands  is  attached.  The  mass  shows  a  central 
circular  patch  of  ablated  skin  on  its  superficial  aspect.  On  its  deep 
aspect  are  seen  the  pectorals,  and  portions  of  the  serratus  magnus 
and  of  the   anterior  layer  of  the  rectus  sheath. 

Haemostasis  and  drainage — Any  bleeding-points  which  have 
escaped  ligature  or  forcipressure  are  now  attended  to.  Two  small 
drainage-tubes  are  inserted  through  punctures  in  the  extreme  base 
of  the  skin  flaps,  one  in  the  epigastric  angle,  the  other  at  the  posterior 
margin  of  the  axilla.  These  tubes  are  removed  at  the  first  dressing, 
twenty-four  hours  later. 

Sutures. — Trial  is  now  made  to  secure  the  best  coaptation  of  the 
edges  of  the  incision.  The  problem  varies  in  each  case  according  to 
the  situation  of  the  growth  in  the  breast,  and  to  the  degree  of  laxity 
of  the  skin.  The  most  striking  indirect  advantage  of  the  operation 
now  becomes  evident.  The  wide  removal  of  the  deep  fascia  so 
mobilizes  and  frees  the  surrounding  skin  that  even  after  the  removal 
of  a  5-in.  circle  of  integument  the  edges  of  the  incision  can  usually 
be  brought  together,  without  the  use  of  tension  stitches,  by  a  single 
continuous  suture  of  fine  catgut.  Tension  in  the  skin  flaps — the 
principal  cause  of  prolonged  shock,  of  pain  and  discomfort  to  the 
patient,  of  impaired  circulation  in  the  skin  flaps,  and  of  delayed  union 
and  ulceration  in  the  sutured  incision — is  thus  entirely  avoided. 

Often  it  will  be  found  best  to  bring  the  edges  together  in  triradiate 
fashion,  in  other  cases  as  a  sinuous  line.  In  growths  of  the  upper 
and  outer  quadrant  some  difficulty  may  be  met  with  in  covering  the 
raw  area,  and  in  these  cases  the  axillary  flap  pf  skin  may  be  pulled 
inwards  to  assist  in  covering  the  thoracic  gap. 

Removal  of  the  supraclavicular  glands. —The  posterior 
triangle  should  be  opened  up,  and  the  supraclavicular  glands  removed 
if  these  glands  are  palpably  enlarged,  or  in  any  event  if  the  subclavian 
glands  at  the  apex  of  the  axilla  are  cancerous,  or  if  the  primary  growth 
is  situated  in  the  upper  hemisphere  of  the  breast.  My  experience  as 
regards  recurrence  shows  that  the  posterior  triangle  should  be  cleared 
much  oftener  than  is  at  present  the  practice  in  this  country,  and  that 
Halsted  and  Rodman  are  right  in  advocating  the  frequent  if  not  the 
invariable  performance  of  this  dissection. 


MAMMARY    GANGER 

After-treatment.  It  is  my  practice  to  confine  the  arm  to 
flic  Bide  until  the  incision  is  healed,  leaving  the  forearm  and 
tree  t"  move.  Sonic  operators  prefei  to  U\  the  tippei  arm  in  an 
abducted  position  to  prevenl  subsequent  binding  oi  the  arm  to  the 
side  .1  danger  which,  in  my  experience,  aeed  nol  be  feared  if,  after 
the  dealing  of  the  incision,  a  course  « » t  massage  is  applied  to  the  Bkin 
nl  the  thorax.     The  abducted  position  fends  to  incre  ion  in 

tlif  flaps,  and  thus  to  interfere  with  healing. 

In  every  case,  as  soon  as  the  wound  is  healed,  a  prophylactic  course 
ol  X-rays  must  be  applied  to  the  thorax,  axilla,  and  supraclavicular 
region— a  precaution  which  1  believe  to  be  imperative.  Four  cases 
only  of  recurrence  in  the  skin  have  come  under  notice  in  my  series 
of  operations,  of  which  three  were  those  of  patients  who  had  not 
undergone  a  prophylactic  course  of  X-rays  (the  percentage  of  my 
patients  who  escape  a  prophylactic  X-ray  course  is  a  very  small  one). 

After  the  operation  for  breast  cancer  a  prolonged  course  of  open-air 
treatment  should  be  advised.  If  the  patient  will  not  consent  to  this. 
she  should,  at  any  rate,  live  as  much  in  the  open  air  as  possible.  A 
sea  voyage  may  he  of  advantage. 

Plastic  operations  in  cancer  of  the  breast. — Much 
ingenuity  has  been  expended  by  surgeons  in  devising  plastic  flaps 
to  fill  the  gap  left  after  removal  of  a  cancer  of  the  breast  (Jackson's, 
Tansini's).  These  operations  are  unnecessary,  for,  if  an  adequate 
area  of  the  deep  fascia  be  removed,  and  if  ablation  of  the  skin  be  not 
pushed  to  the  point  of  unnecessary  sacrifice,  difficulty  in  bringing 
the  flaps  together  is  rare  ;  it  is  only  met  with  in  thin  women  with 
ill-developed  chests.  Immediate  skin-grafting  by  Thiersch's  method 
is  the  best  solution  of  the  difficulty. 

Plastic  methods  are  not  only  unnecessary,  they  are  also  dangerous, 
for  the  tissues  utilized  to  form  the  flap  are  frequently  situated  within 
the  area  of  possible  cancerous  infection. 

Cause  of  death  in  breast  cancer. — Although  dissemina- 
tion is  the  rule,  a  cancer  of  the  breast  may  run  its  course  without 
producing  secondary  deposits.  The  disease  makes  slow  progress 
until  the  viscera  are  attacked.  When  visceral  involvement  declares 
itself,  the  patient  has  usually  but  a  few  months  to  live. 

The  patient  may  die  from  general  dissemination,  from  exhaus- 
tion, from  septic  absorption,  from  deposits  in  the  brain,  from  pleural 
and  pericardial  effusions,  from  ascites,  from  paraplegia  due  to  spinal 
deposits,  and  in  rare  cases  as  the  direct  result  of  bleeding  from  the 
ulcerated  growth.  Intercurrent  diseases,  especially  pneumonia  and  ery- 
sipelas, are  responsible  for  a  certain  number  of  deaths.  The  av< 
duration  of  life  after  the  appearance  of  the  growth  is  stated  by 
Campiche  and  Lazarus-Barlow  to  be  about  four  years. 


94  THE    BREAST 

Treatment  of  inoperable  breast  cancer.  —  In  cases 
where  complete  removal  of  the  growth  is  impossible,  all  that  remains 
is  to  make  the  patient  as  comfortable  as  possible,  and  to  endeavour 
to  delay  the  march  of  the  disease. 

X-rays  in  inoperable  carcinoma — The  principal  use  of  X-rays 
in  breast  cancer  is  as  a  prophylactic  against  postoperative  recurrence. 
But  even  in  advanced  cases  they  are  often  an  effective  means  of 
relieving  pain.  I  have  known  pain  in  the  back  and  thorax  completely 
disappear  for  a  time  after  one  application  of  the  rays,  although  the 
patient  was  utterly  sceptical  of  the  value  of  the  treatment.  In  some 
cases,  however,  especially  when  pain  is  due  to  pressure  upon  deep- 
seated  nerves,  the  rays  are  powerless. 

Apart  from  their  analgesic  properties,  X-rays  promote  the  fibrosis 
and  superficial  healing  of  deposits  in  the  skin  and  subcutaneous  tissues. 
Upon  visceral  and  other  deep  deposits  they  have  no  influence,  nor 
do  they  appear  to  delay  the  course  of  dissemination. 

Open-air  treatment. — I  have  a  strong  impression  that  the  dis- 
ease runs  a  slower  course  in  rural  than  in  urban  patients.  Moreover, 
I  have  observed  that  a  sea  voyage  or  a  stay  in  the  country  sometimes 
retards  its  progress.  The  resemblance  of  the  reactive  or  defensive 
processes  in  cancer  to  those  seen  in  tuberculosis  also  strongly  suggests 
the  advisability  of  systematic  open-air  treatment  in  the  more  chronic 
cases  of  inoperable  cancer.  Experience  has  convinced  me  of  its  value 
in  checking  the  disease. 

Drug  treatment — It  was  formerly  the  practice  to  resort  to 
morphia  as  soon  as  pain  began  to  interfere  with  sleep.  This  practice 
is  much  to  be  deprecated,  for  the  drug  soon  impairs  the  personality 
of  its  habitues,  and  interferes  with  the  action  of  the  stomach,  bowels, 
and  kidneys,  thus  accentuating  the  toxic  or  cachectic  condition  which 
may  be  already  present.  Phenacetin  at  night,  alone  or  combined 
with  caffeine,  will  generally  give  sufficient  relief  to  allow  of  sleep. 
Aspirin  may  be  tried,  but  my  own  experience  of  it  is  disappointing. 
Cannabis  indica  may  also  be  used.  The  aim  should  be  to  defer  the 
use  of  morphia  until  the  last  stage  of  the  disease.  The  drug  will  then 
exert  its  maximum  effect,  unimpeded  by  the  toleration  of  habit,  at 
the  time  when  it  is  most  urgently  needed 

Oophorectomy  in  inoperable  breast  cancer — The 
sudden  cessation  of  menstruation  produced  by  the  removal  of  the 
ovaries  is  known  to  exert  a  powerful  influence  on  general  metabolism, 
and  to  bring  about  regressive  and  fibrotic  processes  in  the  uterus, 
the  breasts,  and  perhaps  in  other  tissues.  Since  carcinoma  tissue  is 
imperfectly  organized,  and  very  subject  to  degeneration  from  mal- 
nutrition of  its  cells,  it  is  not  surprising  that  the  shock  of  an  artificial 
menopause  falls  with  especial  force  upon  it.     As  a  result  the  primary 


LYMPHANGIOPLASTY   FOR  BRAWN!     \KM 

growth  and  large  secondary  deposits  may  shrink  and  disapp  I 

the  patienl   may  regain  her  health  and  activity.     Bui  the  disturbing 
effort  of  the  menopause  upon  the  patient's  genera]  health  ra 
tends  beyond  two  »>r  three  years.     In  the  same  wray  the  carcinoma 
appears  to  recover   from   the  shock-,  and   reasserts   itself   after  the 

lapse    of   a    few  years   only.      And    in    some   Cases    the    progre       of   the 

growth  is  not   even  temporarily  disturbed  by  the  operation. 

Oophorectomy  should  be  reserved  for  inoperable  cases  in  women 

who  are  still  actively  menstruating,  and  who  are  anxious   for  pro- 
longation of  life.    Owing  to  the  uncertainty  oJ  its  action  the  operation 

should  not  be  urged,  though  in  suitable  cases  it  may  fairly  be  offered. 

Beatson,  who  introduced  this  method  of  treatment,  regards  i 
of  acute  carcinoma  and  cases  where  metastatic  growths  are  already 
in  evidence  as  unsuitable  for  oophorectomy.  It  should  be  stated 
that  he  advises  a  subsequent  course  of  thyroid  extract.  J|i-  experi- 
ence shows  no  case  of  permanent  cure.  Though  in  one  instance  the 
disease  remained  in  abeyance  for  six  years,  in  another  for  four, 
and  in  several  for  two  years,  in  a  majority  of  cases  it  reasserted 
itself  within  twelve  months.  In  any  given  case  the  results  of  tie; 
operation  cannot  be  predicted,  but  in  a  large  number  of  cases  the 
general  health  is  improved,  pain  is  relieved,  and  there  is  a  slackening 
in  the  progress  and  activity  of  the  disease.  The  operation  is  probably 
more  beneficial  before  the  menopause,  but,  in  Beatson's  opinion,  is 
not  contra-indicated  in  older  women. 

Treatment  of  lymphatic  oedema  of  the  arm.  —  In 
slight  and  early  cases,  where  the  oedema  still  pits  on  pressure,  habitual 
elevation  of  the  arm,  either  during  the  night  or  for  several  hours  daily, 
will  afford  relief  for  some  time.  Later  on,  in  properly  selected  cases, 
the  writer's  operation  of  lymphangioplasty  affords  great  relief  at 
a  very  small  risk ;  but  it  is,  of  course,  a  palliative  only,  and  does  not 
delay  the  progress  of  the  growth.  In  suitable  cases  the  following 
benefits  may  be  expected :  (a)  Complete  relief  from  pain  within 
twenty-four  hours  unless  the  pain  is  partially  due  to  some  cause,  such 
as  nerve  pressure,  independent  of  the  oedema,  (b)  A  marked  and 
rapid  fall  in  the  tissue  tension  of  the  whole  area  drained  by  the  threads. 
so  that  the  arm  becomes  soft  and  flabby,  (c)  Rapid  subsidence  of 
the  swelling,  commencing  immediately  in  the  hand,  and  extending 
to  the  forearm  within  twenty-four  hours.  At  first  the  upper  arm 
is  unaffected,  or  its  diameters  may  even  slightly  increase  ;  but  within 
a  week  or  two  the  diameters  of  the  upper  arm  also  are  markedly 
lessened.  The  subsidence  is  usually  permanent,  unless  and  until 
pleural  effusion  supervenes  to  interfere  with  drainage.  These  effects 
are  at  first  dependent  upon  the  adoption  of  proper  postural  after- 
treatment,  but,  after  a   few  months,  elevation  of  the  arm  may   be 


96 


THE   BREAST 


entirely  abandoned  without  marked  increase  of  swelling,  (d)  Return 
of  power  to  the  paralysed  arm,  provided  that  the  paralysis  is  of  recent 
date.  Thus,  one  of  my  patients,  whose  arm  was  totally  paralysed, 
was  subsequently  able  to  write  me  a  letter,  (e)  An  improvement  in 
the  general  condition,  dependent  partly  upon  relief  from  pain  and 
insomnia,  and  partly  upon  the  abandonment  of  sedatives. 

Technique   of  lymphangioplasty   for   brawny  arm — The 
special  materials  necessary  are  a  set  of  suitable  probes,  lymphangio- 


Fig.  285. — Diagram  of  the  course  of  the  silk  threads  in 
lymphangioplasty  (front  and  back  of  arm). 

plasty  forceps  with  jaws  specially  designed  to  take  a  firm  grip 
of  either  end  of  the  probe,  and  a  supply  of  Xo.  12  tubular  silk. 
The  tissues  of  the  arm  are  drained  by  two  long  U-shaped  lines 
of  silk,  each  line  composed  of  two  threads  of  Xo.  12  tubular  silk 
(Fig.  285).  One  of  these  lines  drains  the  front  of  the  arm,  the  other 
the  back.  The  bend  of  each  U  lies  immediately  above  the  wrist, 
and  its  two  limbs  occupy  respectively  the  radial  and  ulnar  side  of 
the  limb.  Thus,  along  the  whole  length  of  the  limb  are  found  four 
double  hues  of  silk,  spaced  out  round  the  limb  as  nearly  as  possible 


LYMPHANGIOPLASTY    FOR    BRAWNY     \K\l 

;it  quadrant  intervals,  Towards  the  shoulder  the  linea  of  Bilk  on  the 
flexor  aspecl  curve  outwards  abound  the  deltoid  muscle,  and  con 
to  tneel  the  ascending  threajaa  from  the  posterior  aspecl  at  .1  point 
near  the  posterior  border  of  the  deltoid.  From  tin-  poinl  the  silt 
threads  again  radiate  in  the  subcutaneous  tissue  oi  the  back,  ter- 
minating by  free  ends  in  the  subcutaneous  tissues  oi  the  scapular 
region.  It  is  perhaps  still  better  to  lead  some  of  them  to  the  scapular 
region  of  the  opposite  ade,  and  others  to  the  lumbar  region  of  tin- 
same  side,  if  there  is  any  sign  of  the  oedema  extending  from  the  arm 
to  the  trunk. 

The  operation  is  done  as  follows  :  Take  a  double  line  of  silk-,  rather 
more  than  twice  as  long  as  t  he  arm,  and  mark  its  mid-point  by  clipping 
on  it  a  pair  of  artery  forceps.  Wrap  up  one  half  of  its  Length  in  gauze. 
Thread  t  he  two  ends  of  t  be  o1  her  half  t  hrough  the  eye  of  a  Long  probe. 
Make  an  incision  i  in.  long  through  the  skin  at  the  middle  <>f  t  in-  front 
of  the  forearm,  just  above  the  wrist-joint.  Thrust  the  probe  in  tin- 
desired  line  upwards  in  the  subcutaneous  tissues  well  away  from  the 
skin  towards  the  region  of  the  elbow,  as  high  as  is  convenient,  and 
cut  down  upon  its  point.  Withdraw  the  probe  through  the  incision 
last  made,  and  draw  the  silk  after  it  as  far  as  it  will  come.  Introduce 
the  probe  through  the  incision  from  which  it  has  just  emerged,  thrust 
it  upwards  again  in  the  selected  line,  and  repeat  the  foregoing  steps 
until  the  point  selected  for  the  convergence  of  the  threads  is  reached. 
Here  an  incision  1  in.  long  is  made,  through  which  the  probe  with 
its  two  silk  threads  is  drawn  out.  The  other  half  of  the  silk  loop  is 
now  led  upwards  in  the  selected  line  along  the  other  border  of  the 
flexor  surface.  The  limb  is  turned  over  and  the  extensor  loop  of  silk 
is  similarly  introduced.  When  this  has  been  done,  eight  free  ends  of 
silk  are  hanging  out  from  the  incision  of  convergence  at  the  posterior 
border  of  the  deltoid.  Two  at  a  time,  these  are  tucked  away  in  various 
directions  in  the  subcutaneous  tissues  of  the  back  by  the  following 
manoeuvre  :  Clip  a  forceps  on  the  selected  pair  of  silk  threads  just 
where  it  emerges  from  the  topmost  incision.  Take  a  long  probe, 
cut  off  the  ends  of  the  two  threads  so  that  they  are  4  in.  shorter 
than  the  probe,  and  thread  them  into  the  eye.  Thrust  the  probe 
downwards  from  the  incision  in  the  desired  direction  until  the  probe 
unthreads  itself.  Withdraw  the  probe  carefully,  leaving  the  two  silk 
threads  to  occupy  its  track.  Complete  the  operation  by  sewing  up 
the  incisions  with  horsehair. 

The  principal  difficulties  of  the  operation  are  connected  with  the 
maintenance  of  the  silk  in  an  aseptic  condition.  Owing  to  the  large 
area  dealt  with,  extending  on  to  the  back,  the  necessary  changes  in 
the  posture  of  the  arm,  and  the  length  of  the  silk  threads,  accidental 
contact  mav  very  easilv  occur  between  the  silk  and  the  surface  of 
h 


98  THE   BREAST 

the  skin,  the  edges  of  the  incisions,  or  surrounding  objects.  The  silk 
ends  not  actually  dealt  with  at  the  moment  must  be  kept  wrapped 
in  sterile  gauze,  which  is  also  useful  to  protect  them  from  the  edges 
of  the  incisions  as  they  are  being  drawn  in  after  the  probe.  If  neces- 
sary, all  the  threads  can  be  withdrawn  by  reopening  the  two  incisions 
just  above  the  wrist.  I  have  never  been  obliged  to  do  this.  There 
is  no  need  to  fix  the  upper  ends  of  the  threads  by  knotting  them 
together,  for  the  silk  soon  becomes  adherent  to  the  tissues  along 
its  whole  length. 

Lastly,  it  is  necessary  to  state  that  severe  lymphatic  cedema  of 
the  arm  does  not  usually  develop  until  within  a  few  months  of  the 
patient's  death  from  her  disease.  A  long  period  of  survival  after 
the  operation  must  not,  as  a  rule,  be  expected.  The  aim  of  the 
operation  is  not  the  prolongation  of  that  period,  but  its  conversion 
from  one  of  torture  into  one  of  comparative  comfort. 

Cases  unsuitable  for  lymphangioplasty. — The  operation  of 
capillary  drainage  by  silk  threads  is  contra-indicated  in  cases  where 
a  general  anaesthetic  cannot  be  borne,  and  in  cases  where  the  threads 
would  have  to  pass  through  cancerous  tissue.  It  is  also  inadvisable 
to  operate  if  there  is  growth  present  about  the  shoukler.  or  if  the 
pain  is  mainly  axillary,  or  is  a  lancinating  pain  shooting  down  the  arm. 
In  the  presence  of  pleural  effusion  or  secondary  growths  the  operation 
is  hardly  worth  doing,  for  its  effects  at  best  will  be  transient. 

Amputation  of  the  arm,  or  interscapulo-thoracic  amputation,  is 
the  only  resource  in  cases  unsuitable  for  lymphangioplasty. 

Treatment  of  cancerous  ulcers.  —  Ulceration  of  the 
growth  is  due  primarily  to  necrosis  of  the  central  portions  of  the 
growth  from  nutritional  failure.  But,  unless  care  be  taken,  the  ulcer 
becomes  the  seat  of  septic  processes  and  the  source  of  an  offensive 
discharge.  These  distressing  evils  can  be  prevented  or  mitigated  by 
careful  attention  to  the  antiseptic  dressing  of  the  ulcer.  Strong  anti- 
septics such  as  10-volume  hydrogen  peroxide  at  full  strength,  acetone, 
or  zinc  chloride  40  gr.  to  the  ounce,  may  be  applied  once  or  oftener 
if  the  ulcer  is  foul.  The  separation  of  sloughs  may  be  hastened  by 
hot  fomentations.  Subsequently  the  ulcer  is  dressed  daily  with  mild 
unirritating  applications,  such,  for  instance,  as  boric  lint,  boric  oint- 
ment, or  lint  wrung  out  of  sanitas,  or  solution  of  cyllin  10-20  minims 
to  the  pint. 

SARCOMA   OF   THE    BREAST 

Etiology. — It  is  doubtful  whether  injury  plays  a  definite  part 
in  the  origin  of  carcinoma,  but  there  can  be  little  doubt  that  sarcoma 
of  the  breast  is  occasionally  of  traumatic  origin  (Coley)  ;  that  is  to 
say,  the  sarcoma  develops  at  the  site  of.  and  within  a  short  interval 


MAMMARY    SARCOMA 


alter,  a  single  definite  blow.  Bland-Sutton  has*  drawn  attention  to 
the  possible  medico-legal  importance  of  this  tact. 

Fibroadenoma  and  sarcoma.     A  fibro-adenoma,  after  pei 
ing  for  years  without  marked  change,  may  take  on  rapid  growth,  and 

may  in  a  few    months   form   a    large   tumour    to    whieh    the  nam.-    sofl 

fibro-adenoma   is   applied.     As  a  rule,  when  the  breasl   is  removed, 

the  tumour  is  still  found  to  1 ncapsuled,  and   il   doee  no1    recur. 

In  other  cases  a  small 

tumour  present  for  some 
time  in  the  breast  be- 
gins to  grow  rapidly, 
and  a  large  hemispherical 

mass  is  produced  which 
soon  [ungates  through 
the  skin.  On  removal  an 
unencapsuled  sarcoma  is 
found  to  be  infiltrating 
the  breast.  If  we  re- 
member, in  conjunction 
with  these  facts,  that 
the  microscopic  appear- 
ances of  a  soft  fibro- 
adenoma resemble  very 
closely  those  of  a  sar- 
coma, we  may  explain 
the  statement  made  by 
various  authorities  that 
a  fibro-adenoma  may  be- 
come a  malignant  tumour 
of  the  sarcomatous  type, 

and  that  the  soft  fibro-adenoma  is  either  an  intermediate  form  or 
an  intermediate  stage  in  the  conversion.  These  statements,  though 
not  generally  accepted,  are,  in  my  opinion,  correct.1 

The  routine  histological  examination  of  tumours  of  the  breast 
has  shown  that  sarcoma  of  the  breast  is  much  less  frequent  than  it 
was  formerly  thought  to  be.  Though  some  authors  say  that  one 
malignant  tumour  of  the  breast  in  fifty  is  a  true  sarcoma,  this  is 
probably  an  over-statement.  Many  cases  which  present  the  clinical 
signs  of  sarcoma  turn  out  to  be  soft  carcinomas,  others  to  be  cystic 
adenomas.     Sarcoma  of  the  male  breast  is  excessively  rare. 

Age-incidence. — Though  it  may  occur  at  any  age  from  childhood 
upwards,  Rodman  finds  that  sarcoma,  like  carcinoma,  is  a  disease  of 
middle  life,  and  that  half  the  cases  occur  between  the  ages  of  40  and  50. 
1  But  see  Vol.  I.,  p.  433. 


•V. 


Fig,  2S0. — Spindle-celled  sarcoma  of  the 
breast.  x  250.  Note  the  complete 
disappearance  of  the  normal  glandular 
elements  of  the  breast.  This  is  charac- 
teristic of  sarcoma. 


IOO 


THE   BREAST 


Clinical  signs — A  typical  sarcoma  of  the  breast  is  a  rapidly 
growing  tumour  which  soon  attains  a  large  size.  In  contrast  to 
carcinoma,  the  growth  of  the  tumour  is  not  accompanied  by  any 
shrinkage  or  contraction  of  the  tissues.     The  swelling  formed  is  a 


Fig.  287. — Sarcoma  of  the  breast. 

(Beatson,    Edin.   Med.  Joum.,  Jan,,   1909.) 

large,  prominent,  hemispherical  mass,  soon  involving  the  whole  breast. 
Large  veins  course  over  its  surface,  and  pulsation  may  be  present  in 
it.  The  axillary  glands  usually  remain  of  normal  size.  Soon  the 
skin  adheres  to  the  tumour  over  a  wide  area,  and  the  breast  becomes 
adherent  to  the  pectoral  fascia.  At  the  summit  of  the  swelling  the 
skin  becomes  thinned  and  reddened,  and  finally  gives  way  like  a 
rubber  sheet  under  tension,  exposing  a  vascular  area  of  tumour  tissue. 


MAMMARY    SARCOMA  ioi 

Through  the  opening  thus  formed  a  vascular  mass  "I  growth,  often 
sloughy  in  appearance,  rapidly  protrudes  (Kg.  288),  and  the  patient 
frequently  Bucouxnbs  to  haemorrhage  and  exhaustion  before  dissemi- 
nation has  taken  place.  In  some  rases,  bowever,  niiin-a oufl  secondary 
deposits  are  found  in  I  be  internal  organs,  t  be  bones,  and  I  be  Lymphatic 
elands. 


Fig.  288. — Fungating  sarcoma  of  the  breast. 

Chondro-Sarcoma  of  the  Breast 

In  rare  cases,  sarcomas  of  the  breast  may  contain  areas  of  cartilage. 
Such  chondro-sarcomas  sometimes  undergo  calcification,  or  true  bone 
with  well-marked  Haversian  systems  may  be  formed  in  them.  The 
patients  are  middle-aged  or  old  ;  the  tumours  are  characterized  by 
their  stony  hardness,  but  portions  of  them  may  be  soft  and  fluctuating 
owing  to  the  liquefaction  of  areas  of  cartilage.  These  tumours  may 
quickly  recur  after  operation,  and  may  become  disseminated.  Calcined 
cartilage  has  been  detected  in  the  secondary  deposits  (Bland-Sutton). 

In  a  case  of  chondro-sarcoma  recently  under  my  care  a  duct 
papilloma  had  been  excised  from  the  breast  five  years  previously. 


io2  THE    BREAST 

Treatment  of  sarcoma — Sarcoma  of  the  breast  requires 
an  operation  similar  to  that  for  carcinoma  of  the  breast.  A 
margin  of  at  least  an  inch  must  be  left  around  the  adherent  area 
of  skin,  and  grafting  will  in  many  cases  be  required. 

Most  of  the  photomicrographs  illustrating  this  article  were  kindly 
taken  by  Mr.  R.   W.   Annison,  M.R.C.S.,  from  the  writers  specimens. 

BIBLIOGRAPHY 

Banks,  Sir  Mitchell,  "  Removal  of  Axillary  Glands  in  Breast  Cancer,"  Brit.  Med. 

Joum.,  1882,  ii.  1138. 
Beatson.  Sir  G.  T.,  "Sarcoma  of  the  Female  Mamma,"  Edin.  Med.  Joum.,  Jan., 

1909. 
Benians,  T.  H.  C,  "  The  Use  of  Vaccines  in  Acute  Mastitis,"  Brit.  Med.  Joum., 

April  15,   1911. 
Bland-Sutton,  John,  "  Secondary  (Metastatic)  Carcinoma  of  Ovaries,"  Brit.  Med. 

Joum.,  May  26,  1906 ;  Arch:  of  Middx.  Hosp.,  1910,  xix.  98. 
Boyd,  Stanley,  "  On  Oophorectoniv  in  Treatment  of  Cancer  of    Breast,"  Brit. 

Med.  Joum..  Feb.  4,  1889,  p.  257. 
Campiche   and   Lazarus-Barlow,    "  Malignant  Disease   of    Breast :    a   Statistical 

Study  from  Records  of  Middlesex    Hospital,"  Arch,  of  Middx.  Hosp.,  1905, 

vol.  v. 
Cheatle,    G.    Lenthal,    "  A    Clinical    Lecture    on    Chronic    Traumatic    Mastitis," 

Brit.  Med.  Joum.,  March  4,  1911. 
Coley.  W.  B.,  "  Injury  as  a  Causative  Factor  in  Cancer,"  Ann.  of  Surg.,  May,  1911. 
Gould,   Sir  A.   Pearce,   "  Cases  illustrating  Repair  in  Cancer  of    Breast,"   Clin. 

Joum.,  May  9.  1900. 
Halsted,  Prof.  W.  S.,  "  Removal  of  Breast  and  Axillary  Tissues  in  Breast  Cancer," 

Ann.  of  Surg..  Nov.,  1894. 
Handley,  W.  Sampson,  "  Centrifugal  Spread  of  Mammary  Carcinoma  of  Parietcs, 

and  its    Bearing  on    Operative   Treatment."    Arch,   of  Middx.  Hosp.,   1904, 

vol.  iii.     Cancer  of  Breast  and  its  Operative  Treatment.     London,   1906. 
Heidenhain,   "  Leber  die   Ursachen  der  localen  Krebsrecidive  nach  Amputatio 

Mammae,"  Arch.  f.  Bin.  Chi,:,  18S9,  S.  97. 
Leitch,  Archibald,  Brit.  Med.  Joum.,  May  22,  1SC9.     (A  rapid  staining  method  for 

use  during  operations.) 
Lockwood,    C.   B.,   "  An  Address  on   Carcinoma  of  Breast."   Brit.   Med.   Joum., 

Jan.  27.   1900. 
Moore,    Charles,   ""  Influence   of   Inadequate   Operations  on  Theory  of  Cancer," 

Trans.  Boy.  Med.-Chir.  Soc,  18(57,  i.  245. 
Osier,  Sir  William,  "  Medical   Aspects    of    Breast  Cancer,"  Brit.    Med.    Joum., 

Jan.  6,  1906. 
Paget,  Sir  James,  "  On  Disease  of  Mammary  Areola  preceding  Cancer  of  Mammary 

Gland."  St.  Bart's  Hosp.  Repts.,  x.  87. 
Paget.  Stephen,  "  Distribution  of  Secondary  Growths  in  Cancer  of  Breast,"  Lancet, 

March  23,   1889. 
Rodman,  Prof.  W.  L.,  Diseases  of  the  Breast.     1908. 
Sappey,  Vaisseaux  Lymphatiques. 

Schmidt,  M.   B.,  Die   Yerbreitungswege  der  Karzinome.     Jena,   1903. 
Shaw,  Ernest  H.,  "  Tumours  of  the  Breast,"  St.  Bart.'s  Hosp.  Joum..  May,  1904  ; 

"  The  Immediate  Microscopic  Diagnosis  of  Tumours  at  the  Time  of  Opera- 
tion," Lancet,  Sept.  24,  1910. 
Stiles,  Harold,  "  On  Dissemination  of  Cancer  of  Breast,"  Brit  Med.  Joum.,  1889, 

i.    1452 ;     "  Contributions    to    Surgical    Anatomy  of    Breast,"   Edin.    Med. 

Joum..  1892  ;    article  in  Burghards  System  of  Operative  Surgery. 
Tbrbk  and  Wittelshofer,  "  Statistics  bearing  on  Dissemination  in  Breast  Cancer," 

Arch.  f.  Uin.  Chir..  1881,  xxv.  873. 
Velpeau,  "  Diseases  of  the  Breast,"  Sydenham  Soc.  Trans. 
Williams..  Roger,  Diseases  of  the  Breast. 


^,A 


Paget's  disease  of    the   nipple.     The    nipple  has  been    entirely   destroyed  ; 

its  place  and  that  of   the  areola  are  taken  by  an  intensely  red,  raw,  and 

"  weeping  "  surface  which  extends  considerably  beyond  the  original  limits 

of  the  areola.      A  carcinoma  was  present  in  the  breast. 

[Ftom  a  case  under  the  author's  can-  at  the  Middlesex  I lospii '«/.) 


Plate  82. 


THE     SPLEEN 
By   C.   GORDON   WATSON,   F.R.G.S. 

SPLENECTOMY 

Effects  of  removal  of  the  spleen.  —  The  spleen  can  be  re- 
moved without  causing  any  serious  physiological  disturbance. 

Its  removal  causes  a  transitory  diminution  in  the  number  of  the 
red,  and  a  temporary  increase  in  the  number  of  the  white,  blood- 
corpuscles.  This  deficiency  is  made  up  by  an  increased  activity  on 
the  part  of  the  lymphatic  glands,  of  the  bone  marrow,  and  perhaps 
also  of  the  thyroid  gland,  inasmuch  as  thyroid  hypertrophy  has  in 
some  instances  followed  excision  of  the  spleen.  The  temporary 
ansemia  which  usually  follows  excision  may  in  part  be  accounted  for 
by  the  actual  volume  of  blood  removed  with  the  spleen. 

In  the  initial  leucocytosis  an  increase  of  the  polymorphonuclears 
usually  occurs.  Later  on,  and  coincidently  with  the  lymphatic 
enlargement,  there  is  a  definite  lymphocytosis,  which  has  been  known 
to  continue,  in  patients  under  observation,  for  as  long  as  three  years 
after  removal  of  the  spleen.  Eosinophilia  may  be  observed,  either 
transitory,  or  immediate  and  persisting  for  some  years  after  operation. 
Warthin  has  shown  by  animal  experiments  that  lymphatic  enlarge- 
ment occurs  as  a  compensatory  substitute  for  the  spleen  in  the  sheep 
and  goat.  The  pain  which  is  often  complained  of  along  the  bones 
of  the  limbs  after  splenectomy  suggests  that  the  bone  marrow  takes 
a  part  in  compensation. 

In  some  instances,  after  convalescence  from  splenectomy  there 
has  been  a  gradual  onset  of  progressive  emaciation,  with  general 
weakness,  headache,  thirst,  drowsiness,  and  irritability,  and  some- 
times with  pyrexia,  rapid  pulse  and  respiration.  In  two  cases, 
recorded  by  Ballance,  in  which  this  condition  arose,  ultimate  complete 
recovery  followed  the  administration  of  extract  of  sheep's  spleen 
and  bone  marrow,  and  finally  arsenic.  Possibly  this  train  of  symp- 
toms was  dependent  on  the  loss  of  an  internal  secretion,  and  it  may 
be  that  the  bone-marrow,  lymph-glands,  and  perhaps  the  thyroid,  were 
unable  at  once  to  meet  the  demands  made  upon  them  so  suddenly  to 


io4  THE   SPLEEN 

compensate  for  tlio  loss  of  the  spleen.  In  other  cases  an  element  of 
sepsis  may  afford  a  reasonable  explanation  of  the  symptoms.  The  con- 
dition described  is  certainly  not  a  common  sequela  of  the  operation. 

Splenectomy  should  not  be  lightly  undertaken.  The  mortality 
is  high.  The  chief  dangers  are  shock  and  haemorrhage.  The  size  of 
the  spleen  and  the  presence  of  adhesions  may  present  serious  difficulties. 

G.  B.  Johnston  has  collected  708  cases  of  splenectomy,  showing 
a  mortality  of  274  per  cent.  If  the  cases  of  removal  for  injuries  are 
excluded  (150  with  51  deaths),  the  mortality  is  13-2  per  cent. 

Although  the  spleen  has  been  removed  for  a  great  variety  of  con- 
ditions, the  cases  in  which  splenectomy  is  either  desirable  or  suitable 
are  in  the  main  limited  to  (1)  injuries  or  ruptures  which  endanger 
life  from  hemorrhage ;  (2)  strangulation  of  a  normal  or  diseased 
spleen,  due  to  torsion  of  the  pedicle  ;  (3)  hypertrophy  combined  with 
excessive  mobility,  when  causing  troublesome  symptoms  ;  (4)  primary 
malignant  disease,  if  recognized  early ;  (5)  malarial  hypertrophy, 
when  the  size  of  the  spleen  is  a  menace  to  the  patient's  life  ;  and 
(6)  some  cases  of  splenic  anaemia. 

The  operation. — The  most  convenient  incision  is  a  vertical 
one  along  the  outer  border  of  the  left  rectus.  When  the  diagnosis 
is  uncertain  a  median  incision  is  usually  employed,  and  if  necessary 
the  left  rectus  is  subsequently  divided  transversely.  In  the  case  of 
very  large  tumours,  and  especially  in  women,  in  whom  the  subcostal 
arch  is  less  divergent  than  in  the  male,  the  median  incision  is  probably 
the  most  suitable,  as  it  allows  of  a  longer  incision  than  can  be  secured 
in  the  linea  semilunaris.  Some  surgeons  adopt  an  oblique  incision 
parallel  to  the  costal  arch. 

If  adhesions  exist,  they  must  be  dealt  with  before  any  attempt 
is  made  to  ligature  the  pedicle.  If  adhesions  are  extensive  between 
the  spleen  and  neighbouring  viscera,  it  will  often  be  advisable  to 
abandon  the  operation.  Adhesions  between  the  spleen  and  the 
parietal  peritoneum  are  best  dealt  with  by  gentle  pressure  with  swabs 
on  holders.  Omental  adhesions  must  be  carefully  transfixed  and 
ligatured. 

Before  the  pedicle  is  ligatured  the  spleen  should,  if  possible,  be 
delivered  outside  the  abdomen.  The  pedicle  is  most  easily  approached 
when  the  spleen  is  rotated  so  that  the  posterior  surface  looks  forward. 
The  vessels  should  be  separately  ligatured  with  stout  silk,  and  divided 
at  some  distance  from  the  ligatures.  The  greatest  care  must  be  taken 
to  avoid  undue  tension  or  torsion  on  the  larse  splenic  veins.  Some 
surgeons  have  by  design  included  the  tail  of  the  pancreas  in  the 
ligatures,  to  lend  support  and  security  to  the  vascular  stump. 

It  must  be  remembered  that  the  splenic  artery  breaks  up  into 
from  five  to  seven  branches  when  it  reaches  the  spleen,  and  that  the 


RUPTURE    OF   THE   SPLEEN 

v.isa  brevia  are  branches  of  the  splenic  artery  to  the  greater  curvature 
of   tli<'   Btomach,    running    in    the    gastro-aplenic    omentum.     I 
together  with  the  gastro-epiploica  sinistra  (the  larg    .  supplying 

the  cardiac  <mhI  <>f  the  greater  curvature  of  the  stomach),  should  be 
avoided,  if  possible,  when  separating  the  spleen  from  the  Btomach  by 
division  of  the  gastro-aplenic  omentum.  The  splenic  artery  ends 
by  crossing  the  upper  end  of  the  lefl  kidney,  and  its  terminal  branches 
through  the  lieno-renal  Ligamenl  to  reach  the  hilum,  s<>  thai 
the  close  relationship  of  the  spleen  to  the  kidney  musl  I"-  remembered 
when  the  pedicle  is  dealt  with. 

In  some  instances  dragging  on  the  pedicle  has  produced  alarming 
symptoms  of  collapse,  probably  due  to  injury  <>f  the  splenic  nerve 
plexus,  which  arises  from  the  solar  plexus  and  runs  with  the  splenic 
vessels. 

The  capsule  of  the  spleen  is  normally  very  thin,  and  the  Bplenic 
tissue  very  friable,  so  that  rough  handling  of  the  viscue  is  to  be  avoided. 

RUPTURE— PROLAPSE-TORSION 

RUPTURE    OF    THE    SPLEEN 

In  severe  injuries  to  the  abdomen  (e.g.  when  a  cart-wheel  passes 
over  the  thorax  or  abdomen)  the  spleen  may  be  torn,  severely  lac< 
or  even  severed  from  its  vascular  pedicle.  Such  a  case  generally 
presents  associated  injuries  to  the  liver  or  other  viscera,  with  or  without 
injuries  to  the  bones  of  the  thoracic  wall,  and  seldom  comes  within 
the  range  of  surgical  interference.  In  other  instances  a  crush  or  blow 
upon  the  abdomen  may  produce  an  injury  to  the  spleen  without 
damage  to  other  viscera,  and  be  followed  by  grave  internal  hemorrhage 
which  demands  prompt  operative  treatment.  In  a  few  instances  a 
similar  result  has  followed  a  fall  without  any  direct  blow  upon  the 
abdomen. 

When  the  spleen  is  enlarged,  as  in  malaria,  even  slight  injuries 
have  been  known  to  produce  rupture  of  the  capsule  and  severe  internal 
haemorrhage  (p.  Ill),  and  spontaneous  rupture  of  the  spleen  some- 
times occurs  in  enteric  fever  and  in  splenic  infarction. 

Diagnosis. — Traumatic  splenic  rupture  can  seldom  be  diagnosed 
with  certainty,  but  may  be  assumed  when  signs  of  internal  haemorrhage 
are  associated  with  injury  in  the  splenic  region,  especially  if  at  the 
same  time  the  natural  splenic  dullness  is  increased.  Deepening  pallor, 
restlessness,  great  thirst,  acute  abdominal  pain,  and  faintnee 
combined  with  a  pulse  which  diminishes  in  volume  as  it  in<  rea 
rate  until  it  becomes  running  and  almost  imperceptible.  Abdominal 
rigidity  is  soon  general,  but  is  locally  exaggerated  and  accompanied 


io6  THE   SPLEKX 

by  tenderness  in  the  left  subcostal  region.  If  the  haemorrhage  is 
abundant,  a  shifting  dullness  in  the  flanks  soon  follows — a  valuable 
sign  when  obtained.  If.  when  the  signs  of  fluid  are  increasing,  the 
dullness  in  the  right  flank  can  be  made  to  shift  by  a  change  of  position, 
while  that  in  the  left  remains  constant,  an  injury  to  the  spleen  is 
strongly  suggested.  In  many  cases  of  severe  abdominal  injury  it 
it  is  quite  impossible  at  first  to  arrive  at  any  certain  diagnosis,  and 
it  may  be  difficult  to  decide  whether  a  patient  is  suffering  only  from 
severe  shock,  or  from  collapse  due  to  a  concealed  haemorrhage.1 

Treatment. — In  all  cases  of  suspected  injury  of  the  spleen, 
exploratory  laparotomy  is  imperative  if  there  are  signs  of  internal 
haemorrhage.  The  question  whether  laparotomy  should  be  immediate, 
or  whether  reaction  from  the  shock  and  collapse  incident  to  the  injury 
should  be  awaited,  can  only  be  decided  by  the  circumstances  of  the 
individual  case. 

Speaking  generally,  delay  is  dangerous.  Frequently,  by  slowing 
of  the  heart's  action  and  temporary  clotting,  natural  arrest  of  haemor- 
rhage occurs,  and  encourages  the  surgeon  to  hope  that  by  masterly 
inactivity  he  may  allow  the  arrest  to  become  permanent  without 
subjecting  the  patient  to  the  additional  danger  of  operation  ;  too 
often,  however,  recovery  from  shock  leads  to  a  recurrent  and  not 
seldom  fatal  flood  of  haemorrhage. 

On  the  other  hand,  cases  occur  in  which,  after  the  initial  haemor- 
rhage has  ceased,  recovery  without  recurrence  follows. 

There  are  two  specimens  in  the  Museum  of  St.  Bartholomew's  Hospital 
which  demonstrate  repair  of  the  spleen  after  rupture  from  injury.  One 
(Fig.  289)  is  the  spleen  of  a  woman  aged  30.  who,  falling  30  ft.  from  a  window, 
fractured  her  femur  and  died  ten  days  later,  but  without  symptoms  of 
abdominal  injury.  At  the  autopsy  it  was  apparent  that  the  spleen  had 
been  torn  across,  and  a  firm  white  scar  had  formed  (J  in.  thick),  uniting 
the  lacerated  surfaces.  There  was  also  an  encapsuled  collection  of  blood 
(partly  fluid)  around  the  spleen,  and  the  subperitoneal  tissue  in  the  neigh- 
bourhood was  stained   with  blood  pigment. 

The  other  specimen  (2308b)  was  removed  post  mortem  from  a  woman 
aged  39,  who  was  run  over  by  an  omnibus  and  died  sixty  hours  later.  The 
spleen  had  been  torn  on  the  outer  surface  near  the  upper  extremity,  and 
the  rent  was  closed  by  a  firm  clot. 

Doubtless  similar  specimens  are  to  be  met  with  elsewhere. 

Each  case  must  be  judged  on  its  merits.  Some  cases  are  hopeless 
from  the  first,  but  in  most  the  collapse  resulting  from  the  loss  of  blood 
opens  a  loophole  for  recovery,  although,  as  already  stated,  a  recurrence 
of  haemorrhage  usually  follows.  Occasionally  the  spleen  may  be 
injured  and  yet  no  symptoms  of  haemorrhage  occur  for  many  hours 
or  even  days  after  the  accident.     Possibly  in  some  of  these  cases  the 

J  See  Vol.  I.,  p.  305. 


TREATMENT  OF    RUPTURED   SPLEEN 


'  1 7 


bleeding  first  occurs  beneath  the  capsule,  and  intraperitoneal  haemor- 
rhage only  follows  a  subsequent  rupture  Erom  the  tension  oi  the  blood 
effused  beneath  the  capsule;    In  others  a  temporary  clol  may  occur, 


Fig.  -28U. — Rupture  of  the  spleen  ;   spontaneous  cure.     The  site  of  the 
injury  is  occupied  by  a  firm  white  scar,  measuring  Jr  in.  across. 

{Specimen  230? a.  St.   Bartholomew's  Hospital  Mustiun.) 

and  yield  subsequently  to  a  recurrent  or  secondary  haemorrhage.  If 
the  patient  survive  the  haemorrhage  and  no  operation  be  performed 
he  may  yet  succumb  to  peritonitis,  which  has  often  been  known  to 
follow  large  effusions  of  blood  into  the  peritoneal  cavity. 


!°S  THE    SPLEEN 

In  hospital  practice,  and  in  private  practice  when  surgical  aid  is 
obtainable,  preparation  for  an  operation  should  be  made  as  soon 
as  a  diagnosis  is  established.  Meantime,  absolute  rest  and  freedom 
from  any  disturbance  must  be  enforced.  The  foot  of  the  bed  should 
be  raised,  and  the  extremities  firmly  bandaged.  If  operation  be 
decided  on,  continuous  subcutaneous  saline  infusion  should  be  com- 
menced as  soon  as  the  abdomen  has  been  opened.  For  this  purpose 
the  rubber  bags  designed  by  Arbuthnot  Lane  are  very  efficient.  As 
some  uncertainty  as  to  the  nature  and  extent  of  the  injuries  in  these 
cases  must  always  exist,  it  is  advisable  to  open  the  abdomen  freely 
in  the  middle  line  above  the  umbilicus  so  that  the  liver  and  kidneys 
as  well  as  the  spleen  can  be  examined.  If  it  be  found  that  the  Bpleen 
only  is  ruptured,  further  procedure  will  depend  on  the  extent  of  the 
injury,  and  it  may  then  be  necessary  to  make  an  incision  in  the  left 
linea  semilunaris. 

In  most  cases  splenectomy  (p.  103)  is  advisable.  In  eases  of 
minor  injury,  packing  with  gauze  may  suffice  to  arrest  bleeding,  but 
this  method  is  not  free  from  risk  of  subsequent  hemorrhage,  and  may 
be  followed  by  infection,  suppuration,  and  a  septic  sinus.  In  extreme 
cases,  however,  when  the  collapse  is  so  great  that  excision  seems 
out  of  the  question,  it  may  be  employed.1 

Attempts  to  suture  tears  in  the  spleen  have  usually  failed,  and 
time  devoted  to  this  procedure  will  be  more  profitably  spent  in  liga- 
turing the  splenic  vessels  and  excising  the  damaged  viscus.  If  suture 
be  employed,  the  linked  mattress-suture  should  be  used,  as  less  liable 
to  "  cut  out  "  than  other  forms  of  suture. 

Immediately  the  splenic  origin  of  the  ha?morrha,we  is  ascertained 
an  assistant  should  secure  and  digitally  compress  the  splenic  vessels 
until  the  surgeon  is  prepared  to  ligature  these  and  remove  the  organ. 
At  the  conclusion  of  the  operation  all  blood-clot  should  be  removed 
from  the  abdomen,  and  the  peritoneal  cavity  flushed  out  with  hot 
saline  solution  (115-120°  Fahr.).  The  abdominal  flushing  can  be 
commenced  as  soon  as  the  abdomen  is  opened,  and  carried  on  con- 
tinuously by  an  assistant  while  the  surgeon  proceeds  with  the  operation. 
As  a  rule,  drainage  is  unnecessary.  As  much  saline  solution  as  possible 
should  be  left  in  the  peritoneal  cavity.  Rectal  or  subcutaneous 
infusion  should  be  continued  after  the  operation,  and  regulated  by 
the  condition  of  the  pulse. 

Complications. — Sepsis  is  the  complication  most  to  be  feared. 
Pneumonia   and  empyema  frequently  follow  operation,   and  may  be 

1  D'Arcy  Power  successfully  plugged  the  splenic  area  in  the  ease  of  a  boy  who 
was  kicked  by  a  horse  and  who  developed  symptoms  of  severe  haemorrhage  two 
days  after  the  injury.  Encouraged  by  this  success,  he  employed  the  same  method 
on  the  next  occasion  that  he  operated  for  ruptured  spleen,  but  unfortunately 
the  haemorrhage  recurred  and  death  resulted. 


PROLAPSE  OF   THE   SPLEEN 

explained,  in  some  cases  al   any  rate,   by  associated  injuri* 
lung  and   thoracic    wall.     In   othei  subphrenic   ab  faecal 

fistula,  and   secondary    haemorrhage    have   occurred.     All   these  com- 
plications may  follow   injury  to  the  Bpleen  withoul   operation. 

Other  possible  complications  which  require  brief  mention  are — 
(1)  recurreni  hemorrhage,  which  may  either  resull  from  the  slipping 
of  a  ligature  or  arise  from  points  of  adhesion  as  the  blood 
increases  after  recovery  from  collapse;  (2)  secondary  haemorrhage 
from  sepsis;  (3)  the  obscure  train  of  symptoms  already  mentioned 
(p.  103)  ;  (1)  thrombosis  of  the  splenic  vein,  which  may  extend  to 
the  mesenteric  veins  and  so  give  rise  to  grave  abdominal  symptoms. 

PROLAPSE    OF    THE    SPLEEN 
(Movable,  Wandering,  Ectopic  Spleen) 

This  condition  is  rare  in  men,  and  more  frequent  in  women  who 
have  borne  children.  Although  abnormal  mobility  of  an  otherwise 
natural  spleen  may  occur,  particularly  in  cases  of  general  enteroptosis, 
prolapse  is  usually  associated  with  hypertrophy.  When  the  phrenico- 
colic  ligament,  which  normally  suspends  the  spleen  beneath  the 
diaphragm,  is  stretched  or  torn  the  spleen  readily  prolapses,  and  is 
then  very  imperfectly  supported  by  the  splenic  vessels,  the  gastro- 
splenic  omentum,  and  the  lieno-renal  ligament. 

A  movable  spleen,  if  not  greatly  enlarged,  may  give  rise  to  no 
symptoms  at  all.  Great  mobility,  especially  if  combined  with  con- 
siderable hypertrophy,  induces  severe  spasms  of  pain  closely  simulating 
those  of  movable  kidney.1  Owing  to  the  close  connexion  between 
the  spleen  and  the  stomach  through  the  gastro-splenic  omentum, 
gastric  disturbances  are  not  uncommon. 

In  extreme  cases  the  spleen  may  be  found  to  occupy  the  left  iliac 
fossa,  or  to  have  crossed  to  the  right  of  the  middle  line,  and  it  has 
been  found  impacted  in  the  pelvis. 

The  loss  of  the  normal  splenic  dullness,  the  absence  of  colon 
resonance  in  front  of  the  wandering  viscus,  its  superficial  position, 
and  its  notched  border  should  serve  in  most  cases  to  distinguish  it 
from  a  movable  kidney. 

Treatment. — A  well-fitting  abdominal  belt  may  in  some 
instances  prevent  the  pain  and  discomfort  which  sometimes  result 
from  a  prolapsed  spleen.  In  severe  cases,  especially  in  idiopathic  or 
malarial  hypertrophy,  excision  (p.  103)  may  be  justifiable  if  the  patient 
is  so  inconvenienced  as  to  be  unable  to  follow  his  employment  or  to 
enjoy  active  exercise.     In  a  few  cases  the  operation  of  splenopexy 

1  I.  Macdonald  and  W.  A.  Mackay  record  an  operation  in  a  case  of  movable 
and  twisted  spleen  which  was  mistaken  for  movable  kidney. 


no  THE   SPLEEN 

has  been  performed.  An  incision  is  made  through  the  parietal  peri- 
toneum under  the  left  cupola  of  the  diaphragm,  and  the  peritoneum 
freed  from  the  parietes  until  the  spleen  can  be  passed  through  the 
parietal  peritoneum  and  couched  in  such  a  way  as  to  lie  in  contact 
with  the  diaphragm  over  the  area  from  which  the  peritoneum  has 
been  stripped  and  to  which  it  should  become  adherent.  It  should 
be  kept  in  position  by  suturing  the  stripped  peritoneum  together 
round  the  pedicle  of  the  spleen.  If  firm  adhesions  quickly  form,  and 
the  spleen  is  not  greatly  enlarged,  this  operation  may  be  successful, 
but  if  not,  the  weight  of  the  spleen,  the  stretched  pedicle,  and  the 
constant  movement  of  the  diaphragm  are  factors  which  militate  against 
fixation.  Absolute  rest  on  the  back  should  be  enforced  for  at  least 
a  month  after  the  operation. 

TORSION    OF   THE   SPLEEN 

The  movable  or  wandering  spleen,  especially  if  enlarged,  is  very 
liable  to  become  twisted  on  its  vascular  pedicle  and  to  undergo  stran- 
gulation through  obstruction  to  the  blood  supply  and,  ultimately, 
gangrene  with  thrombosis  of  the  splenic  vessels.  The  condition  is 
analogous  to  the  twisting  of  the  pedicle  of  an  ovarian  cyst  or  a  re- 
tained testis,  and  the  symptoms  are  very  similar — acute  abdominal 
pain   and  vomiting,  and  later,  if  unrelieved,  general  peritonitis. 

The  strangulation  may  come  on  gradually,  or  quite  suddenly,  and, 
if  a  movable  spleen  has  not  been  previously  recognized,  may  so  closely 
resemble  acute  perforation  of  a  viscus  or  intestinal  obstruction  as 
to  escape  diagnosis  before  laparotomy. 

Treatment. — The  only  satisfactory  method  of  treatment  is 
that  of  splenectomy.  Splenopexy,  or  simple  relief  of  the  strangula- 
tion, is  liable  to  be  followed  by  recurrence.  It  will  be  remem- 
bered that  normally  the  spleen  is  slung  beneath  the  arch  of  the 
diaphragm  by  the  phrenico-colic  ligament,  and  closely  connected  to 
the  greater  curvature  of  the  stomach  by  the  gastro-splenic  omentum, 
and  to  the  left  kidney  by  the  lieno-renal  ligament.  The  tail  of 
the  pancreas  lies  in  contact  with  the  hilum  of  the  spleen  just  below 
the  point  of  entry  of  the  large  vessels.  All  these  points  should  be 
borne  in  mind  in  dealing  with  torsion  of  a  prolapsed  spleen. 

HYPERTROPHY 

IDIOPATHIC    AND    MALARIAL   HYPERTROPHY 

Chronic  splenic  enlargement  without  obvious  cause  is  not  common 
in  this  country,  but  White  Hopkinson  states  that  in  Southern  China 
and  the  Malay  States  it  occurs  in  about  90  per  cent,  of  the  population. 
Some  cases  may  be  explained  by  past  acute  infective  disease  or  by 


HYPERTROPHIED   SPLEEN 

latent    malarial    infect  ion.      Others   are    probably   due   to   in, 

syphilis.  Such  an  enlarged  spleen  is  liable  to  prolapse,  and  therefore 
to  cause  not  only  inconvenience  luii  danger  brom  torsion  oi  the  pedicle, 
intestinal  obstruction,  or  pressure  on  other  organs. 

('limine  malaria  is  by  Ear  the  commonest  cause.  A  malarial  spleen 
(ague-cake)  may  attain  an  enormous  size  and  become  a  vei 
burden  to  the  owner.  The  soft  and  moderately  enlarged  spleen  of 
acute  malaria  usually  yields  to  medical  treatment.  The  hyper- 
trophied  spleen  of  chronic  malaria  may  exist  for  many  years  without 
giving  rise  to  symptoms.  Excessive  hypertrophy^  combined  with 
abnormal  mobility,  leads  to  considerable  risk  of  rupture  following  on 
Blight  injury. 

Death  has  been  known  to  ensue  in  a  few  minutes  after  "turning 
in  bed/'  a  "  flick  with  a  cane,"  a  "  dig  in  the  ribs  "  (Battle).  The 
late  Surg.-Gen.  Coull-Mackenzie  states  that  68-9  per  cent,  of  cat 
rupture  of  malarial  spleen  ended  fatally  within  half  an  hour.  A  not 
uncommon  method  of  assassination  in  Southern  China  is  by  a  blow  in 
the  abdomen  with  a  cruciform  iron  instrument  known  as  a  "larang  " 
((  Ya  wford).  Rupture  of  a  malarial  spleen  may  be  compared  to  that  of  an 
aneurysm  ;  rupture  of  a  normal  spleen  to  that  of  a  large  artery  (Battle). 

Treatment. — The  large  spleen  of  chronic  malaria  is  ( often 
accompanied  by  extreme  anaemia,  and  for  this  reason,  as  also  for 
extreme  mobility  and  torsion,  or  to  avoid  the  risk  of  torsion  or  rupture, 
has  been  frequently  removed.  According  to  Jonnesco,  "  to  remove 
the  spleen  is  to  remove  the  breeding  place." 

Statistics  showT  that  the  mortality  of  the  operation  is -high  both 
for  malarial  and  for  so-called  idiopathic  hypertrophy,  but  Johnston's 
table  indicates  that  the  mortality  is  much  lower  when  the  hyper- 
trophy is  accompanied  by  increased  mobility.  This  fact  is  prob- 
ably accounted  for  by  the  comparative  ease  with  which  a  movable 
spleen,  even  though  of  considerable  size,  can  be  delivered  outside 
the  abdomen.  The  rate  of  mortality  for  so-called  idiopathic  hyper- 
trophy and  simple  malarial  enlargement  (in  the  absence  of  ectopia 
or  torsion)  is  not  encouraging  to  the  surgeon. 

Vanverts  states  that  of  39  splenectomies  for  malarial  hypertrophy 
with  adhesions  28  died,  whereas  out  of  35  for  hypertrophy  without 
adhesions  only  2  succumbed. 

Operation  is  only  indicated  when  the  condition  is  complicated  by 
excessive  mobility,  and  when  by  reason  of  the  patient's  occupation 
there  is  danger  of  rupture  or  torsion. 

HYPERTROPHY    IN    SPLENIC   ANJEMIA 

This  is  a  disease  of  young  adult  life,  and  should  be  distinguished 
from  the  ansemias  of  infancy,  which  are  often  associated  with  splenic 


ii2  THE   SPLEEN 

enlargement.  It  can  be  distinguished  from  leukaemia  by  the  blood 
count,  and  from  Hodgkin's  disease  by  the  absence  of  glandular 
enlargement.  For  an  account  of  this  disease  the  reader  is  referred 
to  the  medical  textbooks. 

Briefly,  the  spleen  erdarges  pari  passu  with  progressive  anaemia, 
diarrhoea,  vomiting,  and  intestinal  haemorrhage.  No  enlargement  of 
the  lymphatic  glands  occurs,  and  death  usually  results  from  exhaus- 
tion. The  first  change  in  the  blood  is  a  diminution  of  haemoglobin, 
and  to  a  lesser  degree  of  red  corpuscles.  Later  the  diminution  of  red 
corpuscles  and  haemoglobin  becomes  extreme,  and  small,  imperfectly 
formed,  and  nucleated  red  cells  may  be  found.  The  eoagulability 
of  the  blood  is  also  diminished.  The  white  corpuscles  are,  as  a  rule, 
both  actually  and  relatively  fewer.  The  differential  count  should  show 
no  marked  changes,  and  myelocytes  are  absent.  The  spleen  is  always 
enlarged,  often  to  five  or  ten  times  its  usual  size.  Atrophy  and  sclerosis 
of  the  Malpighian  bodies  has  been  noted  by  Banti — a  point  of  differ- 
entiation from  leukaemia.  It  is  important  not  to  mistake  for  splenic 
anaemia  the  enlarged  spleen  which  may  accompany  portal  hepatic 
cirrhosis. 

Treatment. — Osier  advises  operation  in  chronic  cases  with 
recurrent  attacks  of  haemorrhage  (intestinal).  Sippey  regards  the 
disease  as  fatal  unless  relieved  by  surgical  interference.  Of  the 
61  cases  collected  by  Johnston,  49  recovered  after  operation.  Medical 
treatment  in  the  past  has  been  very  unsuccessful  in  checking  the 
progress  of  the  disease.  If  we  assume  that  the  enlargement  of  the 
spleen  is  the  essential  feature  of  the  disease,  splenectomy  seems  to 
offer  the  best  chance  of  cure. 

V  HYPERTROPHY    IX    BAXTIS   DISEASE 

This  disease  is  characterized  by  a  progressive  enlargement  of  the 
spleen  due  to  overgrowth  of  its  connective  tissue,  with  atrophy  of 
the  pulp  and  Malpighian  bodies.  In  the  later  stages  the  hypertrophy 
is  associated  with  an  atrophic  cirrhosis  of  the  liver.  The  disease 
closelv  resembles  splenic  anaemia,  and  some  authorities  regard  it  as 
a  late  stage  of  that  affection. 

Banti's  cases  showed  an  increase  in  the  marrow  of  the  long  bones 
and  a  return  to  the  red  or  foetal  conditions.  There  are  extreme 
anaemia,  cachexia,  and  wasting. 

Many  cases  of  this  disease  have  been  cured  by  excision  of  the 
spleen.  Hagen  records  16  cases  of  splenectomy  for  Band's  disease, 
with  13  recoveries.  Two  of  the  patients  were  in  excellent  health  8 
and  6i  years  respectively  after  operation  (Collins  Warren  and  Harvey 
Cushing). 

Failing  operation,  the  disease  progresses  steadily  to  a  fatal  issue. 


\i;s<   i  ss   OF    THE   SPLE1  \  H3 

c   BYPERTROPHY     I  N     LEI  K  .KM  f  \ 

The   distinction    between    splenic    [euksBmia    and   Bplenic   anemia 
can  only  be  made  by  a  differentia]  Mood  examination.     The  < ■• 
teristic  change  in  tin'  blood  is  the  presence  of  myelocytes  and  a 
increase  to  the  total  number  of  white  corpuscles. 

Treatment. — In  Johnston's  table  only  6  out  of  49  cases  of 
splenectomy  for  leukaemia  survived  operation.  This  heavy  mortality 
would  suffice  to  contra-indicate  operation,  apart  from  tin;  fact  that 
enlargement  of  the  spleen  is  only  one  manifestation  of  a  general  disease, 
and  that  its  removal,  although  relieving  the  abdomen  of  a  heavy 
burden.  i>  unlikely  to  check  the  progress  of  the  disease  should  the 
it   survive  the  operation. 

INFLAMMATIONS 

ABSCESS 

In  general  blood  infections  the  spleen  is  frequently  the  seat  of 
acute  congestion.  The  circulation  in  the  large  capillaries  and  vein-  is 
slow,  and  the  walls  of  the  vessels  are  very  pervious,  so  that  micro- 
organisms are  readily  deposited  from  the  blood-current.  Abscess  of 
the  spleen  may  occur  in  the  course  of  acute  infective  diseases,  or  in 
any  general  pya?mia.  It  not  uncommonly  results  from  the  breaking 
down  of  a  septic  infarct,  e.g.  in  infective  endocarditis,  and  sometimes 
follows  on  injuries,  the  abscess  probably  resulting  from  the  breaking 
down  of  a  haeniatoma. 

The  pneumococcus  has  been  found  in  some  cases  of  acute  splenic 
abscess  (Fig.  290),  and  J.  P.  Maxwell  has  recorded  2  cases  of  splenic 
abscess  in  South  China  in  which  he  found  the  amoeba  of  dysentery. 

Chronic  suppuration  may  be  due  to  tuberculosis,  actinomycosis, 
or  hydatid  disease,  or  result  from  the  breaking  down  of  a  gumma  or 
a  septic  infarct. 

A  splenic  abscess  may  rupture  and  invade  the  general  peritoneal 
cavity,  the  subphrenic  space,  the  stomach,  or  the  colon,  or  may  burst 
through  the  diaphragm  and  cause  an  empyema. 

Perisplenitis  and  adhesions  readily  form.  The  area  of  splenic 
dullness  increases,  and,  when  adhesions  form  with  the  abdominal  wall, 
localized  swelling  and  oedema  may  occur. 

Diagnosis. — The  diagnosis  of  splenic  abscess  is  based  on  the 
general  signs  and  symptoms  of  suppuration — a  septic  temperature, 
leucocytosis,  etc. — and  the  local  signs  of  pain,  tenderness,  and  swelling 
in  the  situation  of  the  spleen.  The  condition  may  generally  be  dis- 
tinguished from  renal  suppuration  by  the  absence  of  colon  resonance 
between  the  tumour  and  the  anterior  abdominal  wall. 


n4 


THE   SPLEEN 


Treatment. — The  treatment  follows  general  surgical  principles. 
In  several  cases  the  spleen  has  been  excised,  but  in  the  majority  of 


Fig.  290. — Single  abscess  of  the  spleen.  The  specimen  was  removed 
from  a  man  aet.  49,  who  died  with  pneumonia.  It  weighed  50  oz. 
unopened,  was  adherent  to  the  diaphragm,  and  contained  a 
reddish-brown  turbid  fluid.  The  right  lung  was  consolidated, 
and  contained  an  abscess  with  similar  contents. 

(Specimen  2295L,  St.   Bartholomew's  Hospital  Museum.) 

cases  the  operation  would  be  not  only  difficult,  but  dangerous  owing 
to  the  adhesions  and  the  risk  of  rupture  of  the  abscess  and  infection 


INFARCTION   OF   THE   SPLEEN 

of  tlir  peritonea]  cavity.  Splenotomy  with  free  drainage,  ii  pi 
1>\-  mm  incision  ln-lou  the  costal  arch,  or,  after  resection  "i  .1  portion 
i»f  m  ril>  or  ril.s,  In-low  tin-  1 » •  \ .  1  of  the  base  of  the  lung,  should  be 
idopted  in  most  cases.  If  no  adhesions  earisl  between  the  Bpleen 
and  the  anterior  abdominal  wall,  the  greatesl  care  must  be  taken  to 
avoid  infection  of  the  genera]  peritonea]  cavity.  Before  the  abac* 
opened,  the  surrounding  area  must  be  carefully  packed  with  gauze, 
and,  when  the  pus  has  been  evacuated,  the  abscess  wall  should  be 
sutured  to  the  parietes.  Or  the  operation  may,  if  the  case  is  nol  argent, 
be  performed  in  two  stages:  after  the  spleen  has  been  exposed  and 
the  abscess  localized,  the  wound  is  packed  until  the  spleen  becomes 
adherent,  and  the  abscess  is  not  opened  till  aboul  two  days  Later. 

INFARCTS 

Infarction  of  the  spleen  consequent  on  infective  endocarditis  or 
some  other  general  infection  does  not  come  within  the  scope  of  -m ■-< m  \ . 

Occasionally  infarction  may  follow  thrombosis  of  the  splenic  or 
portal  vein,  and  under  such  conditions  the  infarct  may  rupture  and 
give  rise  to  haemorrhage  or  general  peritonitis  (Collins  Warren). 

In  the  Museum  of  St.  Bartholomew's  Hospital  there  is  a  specimen 
(1914c)  illustrating  a  chronic  gastric  ulcer  in  the  cardiac  region, 
with  thrombosis  of  the  splenic  vein  and  an  infarct  of  the  spleen.  The 
patient  succumbed  after  severe  hsematemesis.  In  this  case  the  throm- 
bosis and  infarction  undoubtedly  followed  the  ulceration,  spreading 
from  one  of  the  gastric  vessels  which  join  the  splenic  vein.  Throm- 
bosis of  the  splenic  vein  is  not  uncommonly  met  with  in  infarction 
of  the  spleen,  and  also  in  cases  of  torsion  of  the  spleen,  and  may 
lead  to  severe  hsematemesis.  Tlris  is  illustrated  by  a  specimen  (St. 
Bartholomew's  Museum,  2271b)  of  a  large  pancreatic  cyst  which 
produced  fatal  hsematemesis  owing  to  pressure  on  and  subsequent 
thrombosis  of  the  splenic  vein. 

An  infarcted  spleen  may  rupture  spontaneously  or  from  slight 
violence.  A  case  is  recorded  by  Collins  Warren  of  rupture  of  an 
infarcted  spleen  simulating  an  acute  perforation  of  a  gastric  ulcer, 
for  which  laparotomy  was  performed.  A  quantity  of  blood  was  found 
in  the  peritoneal  cavity,  and  a  large  rent  in  the  spleen.  The  spleen 
was  removed,  but  the  patient  succumbed.  At  the  autopsy  the  portal 
and  splenic  veins  were  found  thrombosed.  "Warren  says  :  "  It  would 
seem  highly  probable  that  distension  of  the  capsule  nearly  to  the 
bursting-point  by  the  cutting  off  of  the  egress  of  the  blood  by  throm- 
bosis of  the  splenic  vein  had  prepared  the  way  for  rupture  of  flu* 
capsule  by  slight  violence." 

Should  an  infarct  of  the  spleen  break  down  and  result  in  an  al 
it  may  require  to  be  dealt  with  on  the  lines  already  laid  down  (p.  114). 


n6 


THE   SPLEEN 


TUBERCULOSIS 

In  generalized  tuberculosis  the  spleen  is  very  commonly  affected. 
Occasionally  primary  caseous  tubercle  develops  in  the  spleen  and 
may  require  to  be  treated  surgically,  either  by  excision  when  exten- 


Fig.  291. — Actinomycosis  of  the  spleen.  From  a  woman  aet.  35, 
who  also  had  extensive  actinomycosis  of  the  liver.  The  upper 
pole  of  the  spleen  is  seen  to  be  adherent  to  the  diaphragm 
and  liver. 

[Specimen  2506c,  -S7.  Bartholomew's  Hospital  Museum.) 

sively  involved,  or  by  splenotomy,  scraping,  and  drainage  if  adhesions 
are  extensive  or  if  the  deposit  of  tubercle  is  limited  to  a  single  focus 
and  the  spleen  not  greatly  implicated. 


INFLAMMATIONS   OF   THE   SIM  I  I  \ 


"7 


\<  TINOMYCOSI8 
Actinomycosis  is  Bometimes   mel    with   in   the  spleen   (Fig. 
though  far  less  frequently  than  in  the  liver.     Should  the  condition 
be  recognized  befoiv  adhesions  have  formed,  and  before  suppuration 


Fig.  292. — Gumma  of  the  spleen. 

lias  spread  to  the  abdominal  wall,  excision  of  the  spleen  is  indicated. 
Usually  it  will  only  be  possible  to  deal  with  the  case  on  lines  appro- 
priate to  chronic  suppuration.  Surgical  treatment  should  be  supple- 
mented by  large  closes  of  iodide  of  potassium,  increased  up  to  200  gr. 
per  diem,  and  a  vaccine  treatment  may  be  tried. 


"8  THE   SPLEEN 

GUMMA 

Largo  gummata  are  sometimes  met  with  in  the  spleen  (Fig.  292), 
and  are  not  easily  diagnosed  without  an  exploratory  operation.  The 
spleen  has  been  excised  on  several  occasions  for  this  condition,  when 
the  gumma  has  failed  to  respond  to  antisyphilitic  remedies. 

Some  cases  of  chronic  hypertrophy  of  the  spleen  are  regarded 
as  syphilitic,  and  it  is  advisable  to  administer  iodide  of  potassium  in 
all  cases  of  hypertrophy  of  uncertain  origin. 

NEOPLASMS 

HYDATID    CYST    OF    SPLEEN 

Cases  of  solitary  hydatid  cyst  of  the  spleen  are  rare.  These 
growths  may  attain  an  enormous  size,  and  have  been  mistaken  for 
ovarian  cysts  (Plate  85). 

Not  infrequently  the  cyst  becomes  calcified  and  obsolete. 

When  suppuration  ensues,  adhesions  readily  form,  and  rupture  is 
liable  to  take  place,  especially  in  the  case  of  large  cysts.  Often  there 
are  no  symptoms  other  than  that  of  a  tumour,  although,  if  the  cyst 
is  large  and  the  spleen  mobile,  there  may  be  symptoms  of  pressure 
or  traction  on  the  stomach  or  other  viscera. 

Fluctuation  or  hydatid  thrill  may  sometimes  be  obtained. 

Treatment. — Exploratory  puncture  should  never  be  employed. 
If  the  cyst  is  of  moderate  size  and  adhesions  are  limited,  splen- 
ectomy is  advisable,  but  considerable  caution  is  necessary  to  avoid 
rupture  in  dealing  with  adhesions. 

In  most  cases  it  is  safest  to  fix  the  cyst  wall  to  the  parietes,  and 
to  incise  and  drain. 

Single  blood  cysts,  serous  cysts,  lymph  cysts,  and  a  few  rare  instances 
of  dermoid  cysts  have  been  met  with  in  the  spleen. 

CAVERNOUS  ANGIOMA 

A  few  cases  of  this  rare  disease  have  been  recorded  for  which  the 
spleen  has  been  successfully  removed  (Hoge). 

The  spleen  to  the  naked  eye  is  dark,  soft,  and  highly  vascular. 
Microscopically  the  capillary  system  is  lost,  and  the  blood  collects  in 
a  number  of  freely  intercommunicating  spaces  closely  resembling  in 
structure  the  corpus  cavernosum  of  the  penis.  The  walls  of  these 
spaces  consist  of  thin  connective  tissue  with  an  epithelial  lining. 

SARCOMA 
The   spleen,   though   sometimes   attacked   by   secondary   deposits 
both  of  carcinoma  and  of  sarcoma,  is  very  seldom  the  seat  of  primary 
sarcoma  (Fig.  293). 


Large  hydatid  cyst  of  the  spleen.  From  a  woman  aged  54,  who  died 
of  acute  bronchitis  in  an  asylum.  There  were  no  symptoms  to  draw 
attention  to    the  spleen.     No  other    hydatid  cysts  were  found  post 

mortem. 
(Specimen  236011,  St.  Bartholomews  Hospital  Museum.') 


Plate  85. 


Fig.  293.— Primary  round-celled  sarcoma  of  spleen.  Removed  from 
a  woman  aet.  49,  who  had  suffered  for  a  week  with  pain  eight 
months  prior  to  operation,  and  since  then  had  been  much  sub- 
ject to  vomiting.    She  made  a  good  recovery  from  the  operation. 

{Specimen  230,0.  St.   Bartholomew's  Hospital  Museum.) 


Bartholomew' 
119 


i2o  THE   SPLEEN 

A  sarcoma  arising  in  the  spleen  will  grow  rapidly  and  give  rise  to 
a  hard,  irregular  tumour.  Metastasis  will  occur  early,  and  wasting 
with  cachexia  may  be  the  only  symptoms  to  attract  attention.  Pain 
is  not  likely  to  occur  in  the  early  stages  unless  the  tumour  is  on  the 
surface  and  the  peritoneum  is  involved.  In  some  cases  a  leucocytosis 
together  with  eosinophilia  has  been  noted. 

The  diagnosis  of  sarcoma  will  usually  be  made  by  a  process 
of  exclusion.  Splenic  ansemia,  leukaemia,  and  malarial  enlargement 
can  be  excluded  by  the  absence  of  the  characteristic  changes  in  the 
blood,  or  by  the  history  of  the  case. 

Prognosis  and  treatment. — If  recognized  early,  and  if 
splenectomy  is  performed  before  metastases  have  formed,  the  prognosis 
may  be  not  unfavourable.  Johnston  has  collected  12  cases  of  splenec- 
tomy for  sarcoma,  with  9  recoveries  from  the  operation.  It  is  probable 
that  if  the  after-histories  of  these  cases  were  traced  it  would  be  found 
that  death  from  recurrence  had  ultimately  resulted.1 

BIBLIOGRAPHY 

Ballance,  Lancet,  1896,  i.  484. 

Battle,  Annual  Oration  Med.  Soc.  of  London,   1910. 

Bessel-Hagen,  Arch.  f.  klin.  Chir.,  1900,  vol.  lxii. 

Crawford,  D.  G.,  Ind.  Med.  Gaz.,  1902  and  1906. 

Emery,  D'Este,  Lancet,  1907,  i.  1896. 

Hoge,  Med.  Rev.,  Sept.,  1895,  and  Ann.  of  Surg.,  1897,  vol.  xxv. 

Johnston,  G.  B.,  Ann.  of  Surg.,  July,  1908,  p.  50. 

Jonneseo,  Gaz.  des  Hop.,  Oct.  27,  1898. 

Lewis,  Amer.  Journ.  of  Med.  Sci.,   1908.  cxxxvi.   157. 

Macdonald,  I.,  and  W.  A.  Mackay,  Lancet,  1909,  ii.  917. 

Maxwell,  J.  P.,    Lancet,   1909,  vol.  ii. 

Osier,  Amer.  Journ.  of  Med.  Sci.,   Oct.,    1900,  p.  .54. 

Power,  D'Arcy,  Clin.  Journ..  Nov.  28,  1906,  and  St.  Bart's  Hosp.  Repts.,  xliv.  101. 

Sendler,     "Traumatic    Splenic    Abscess,"'     Deuts.    Zeitschr.   f.    Chir.,    1893,    Bd. 

xxxvi.,  Heft  .j. 
Sippey,  Amer.  Journ.  of  Med.  Sci.,  1899,  pp.  42s  "»7n. 
Vanverts,  De  la  Splenectomie,  These  de  Paris,  1897. 
Warren,  Collins,  Ann.  of  Surg.,  May,   1901. 
Warthin,  Contributions  to  Medical  Research,  p.  234.     1903. 

1  In  a  case  of  round-celled  sarcoma  of  the  spleen,  weighing  66  oz.,  successfully 
removed  by  D'Arcy  Power  iFjl:.   293),  death  occurred  six^months  later. 


MALFORMATIONS   OF   THE    FACE,    LIPS, 
AND   PALATE 

By   CYRIL  A.    R.   NITCH,    M.S.Lond.,    F.R.C.S. 

Development  of  the  face  and  lips — At  a  very  early  stage 
of  development  the  stomodseum  app  depression  between  the 

yolk-sac  and  the   anterior  extremity   of  the   embryo.     The  depres- 
sion becomes  deepened  by  the  outgrowth  of  the  heart  immediately 


AUDITORY  CAPSUU. 
,1lSOa*UM  


OPTIC   IVAGIHATION 

-STOH0DA.UH 

CUCCC-PHAFTNOLAL    HtMBKIXE 


AORTIC     BULS 


Fig.  294. — Reconstruction  of  the  anterior  portion  of  ar    embryo 
of  2*15  mm. 

(After  His  and  McMurrich.) 

below  it,  and  by  the  ventral  bend  that  takes  place  at  the  anterior 
extremity  of  the  brain,  until  its  floor,  lined  by  ectoderm,  comes  in  con- 
tact with  the  entoderm  of  the  mesodasum.  These  two  layers  are  known 
as  the  bucco-pharyngeal  membrane  (Fig.  29-1).  They  fuse  together, 
atrophy,  and  disappear,  so  that  by  the  end  of  the  third  week  the 
stomodoeuni  and  mesodseurn  are  continuous  with  one  another.     During 


122  FACE,   LIPS.   AND   PALATF 

the  same  week,  five  processes — one  mesial  (the  frontonasal)  and  four 
Lateral  (the  two  maxillary  and  the  two  mandibular) — bud  out  from 
the  base  of  the  primitive  cerebral  capsule  around  the  margins  of  the 
stoniodseum,  and,  by  their  growth  and  ultimate  coalescence,  enclose 
the  cavity,  which  is  now  termed  the  oro-nasal  cavity,  and  complete 
the  facial  portion  of  the  head  at  the  end  of  the  second  month 
(Kg.  295).   _ 

The  mesial  or  fronto-nasal  process  which  bounds  the  upper  part 
of  the  oro-nasal  cavity  becomes  elevated  on  either  side  of  the  mid- 
line   to    form    two    marked    protuberances,    the    globular    processes. 


HASAL    PIT 
LATERAL  HASAL    PROCESS  — 
MAXILLARY    PROCESS 

MANDIBULAR    PROCESS 


GLOBULAR    PROCESS 
ORO-NASA. 


Fig.  295. — Face  of  an  embryo  of  8  mm. 

■     (A/ter  His  ami  McMurrii  k. ) 

Simultaneously  with  the  formation  of  the  globular  processes,  two 
oval  depressions  or  grooves,  the  nasal  pits,  appear  externally  to  them, 
and  thus  separate  the  lower  end  of  the  fronto-nasal  process  into  three 
parts — a  mesial  nasal  process  with  its  globular  processes,  and  two 
lateral  nasal  processes. 

These  processes  are  in  reality  the  anterior  extremities  of  three 
vertical  septa  that  grow  down  from  the  base  of  the  primitive  cerebral 
capsule  ;  they  are  kept  apart  by  the  gradual  deepening  of  the  nasal 
pits,  and  ultimately  form  the  septal  and  lateral  walls  of  the  nasal 
cavities.  The  portion  of  the  mesial  nasal  process  which  intervenes 
between  the  two  globular  processes  is  divided  into  an  upper  triangular 
and  a  lower  quadrilateral  area  by  a  transverse  ridge  which  later 
becomes  moulded  into  the  tip  of  the  nose.  The  upper  triangular 
area  becomes  the  dorsum  of  the  nose,  the  lower  quadrilateral  portion 


DEVELOPMENT   OF    FAG1      WD    LIPS 

the  columella,  i.e.  the  septum  between  the  anterior  oares.  By  the 
elevation  of  this  median  portion  to  form  the  external  nasal  . 
the  globular  processes  are  enabled  to  Euse  together  to  form  the  middle 
third  of  the  upper  lip  (philtrum)  and  the  premaxilla.  Imperfect 
union  in  this  situation  leads  to  thai  care  malformation,  median  hare- 
lip. While  these  changes  ,nv  taking  place  above,  the  mandibulai 
processes  below  have  unite,!  (in  the  fifth  week)  fco  form  the  mandible, 
lower  lip,  and  chin.     All  thai   is  now  required  to  complete  the   feci 


cerebrum 


maxillary  process 
nasal  field 
/at.  nas.  proc. 

mes.  nas.  proc.  (proc.  glob.) 

mandib.  proc. 
hyoid  arch 


Fig.  296.  — Showing  the  parts  of  the  face  formed  from  the 
nasal,  maxillary,  and  mandibular  processes. 

(From  Keith's  '''Human  Embryology  and  Morphology") 

is  the  closure  of  the  gap  between  the  mandibular  bars  and  the  lateral 
nasal  and  fronto-nasal  processes. 

This  is  effected  by  a  bud-like  projection  known  as  the  maxillary 
process,  which  springs  from  the  upper  border  of  the  base '  of  the 
mandibular  bar  on  each  side,  and  sweeps  inwards  and  forwards  beneath 
the  eye  and  the  nasal  groove,  thereby  separating  them  from  the  oral 
cavity.  Above,  it  blends  with  the  lateral  nasal  process  to  complete 
the  ala  of  the  nose  ;  anteriorly,  with  the  globular  process  to  com- 
plete the  upper  lip  ;  and  below,  with  the  mandibular  bar  to  diminish 
the  size  of  the  oral  aperture.  Therefore,  failure  of  union  between  the 
maxillary  and  either  of  these  three  processes  results  in  facial  cleft, 
lateral  hare-lip,  or  macrostoma.  (Fig.  29G.)  Conversely,  fusion  of 
the  maxillary  and  mandibular  processes  beyond  the  normal  d 
leads  to  microstoma. 


I24 


FACE,   LIPS,   AND   PALATE 


Development  of  the  palate — If  the  interior  of  the  oro- 
nasal  cavity  be  examined  in  a  foetus  of  seven  weeks  (Fig.  297).  the 
olfactory  chambers  will  be  seen  opening  into  it,  by  the  primitive 
ckoanse,  between  the  maxillary  processes  and  the  shelf-like  projection 
from  the  posterior  part  of  the  mesial  nasal  (globular)  process  in  which 
the  premaxilla  is  developed.  Laterally,  two  horizontal  plates  will  be 
noticed  springing  from  the  inner  aspect  of  the  maxillary  processes. 
These,  the  palatal  plates,  grow  inwards  beneath  the  nasal  septum, 


mid  brain 


Fig. 


cerebral  vesicle 

anterior  nares 
upper  lip.  mes.  nas.  proc. 
eye 

premax.  mes.  nas.  proc. 
upper  lip.  max.  proc. 
alueolus  max.  proc. 

pa/at.  proc. 

max.  proc.  (section) 

inner  recess  1st  cleft. 
(Eustach.  tube) 
posterior  nares 
'roof  of  pharynx 
septal  part,  mes.  nas.  proc. 

297. — Showing  the  ingrowth  of  the  palatal  plates  of  the 
two  maxillary  processes  early  in  the  second  month.  The 
openings  erroneously  indicated  as  "  posterior  nares  "  are 
the  primitive  choanae.     {After  Kallmann.) 

(From  Keith's  ''Human  Embryology  <ui<l  Morphology.") 


and,  fusing  from  before  backwards,  first  with  the  premaxilla,  and 
later  with  each  other,  complete  the  hard  and  soft  palates  and  separate 
the  nose  from  the  mouth.  From  this  it  will  be  understood  that 
partial  cleft  palate  is  due  to  defective  fusion  of  the  palatal  processes 
with  each  other  ;  that  complete  cleft  palate  follows  non-union  of  a 
palatal  plate  with  the  premaxillary  process  in  front  and  the  opposite 
palatal  plate  behind  ;  and  that,  in  complete  cleft  palate  and  hare-lip, 
the  line  of  cleavage  passes  between  the  maxillary  and  palatine  pro- 
cesses externally,  and  the  globular,  premaxillary,  and  palatine 
processes  mesially.  As  the  process  of  fusion  spreads  from  before 
backwards,  partial  cleft  palate  occurs  with  greater  frequency  than 
complete  cleft  palate,  and  a  complete  cleft  is  not  always  accom- 
panied  by  hare-lip.     Similarly,   partial   or  complete   hare-lip   is   not 


DEVELOPMENT  OF   THE    PREMAXILLA 


sarily  associated  with  cleft  palate,  for,  ae  Big.  297  dear] 
the  upper  lip  is  completed  by  the  union  of  the  maxillary  and  globular 
processes,   whilst  the  palate  is  fashioned   from  the  three   horizontal 
plates  which  grow  inwards  from  these  processes. 

foetal  palate  has  a  very  high  arch,  for  I  be  palatal  plates  develop 
in  an  upward  as  well  as  a  horizontal  direction,  in  the  endeavour, 
were,  to  meet  the  nasal  septum,  with  which  they  eventually  fuse. 
This  peculiarity  of  growth  accounts  for  the  frequent  combination  of 
a  high  arch  with  cleft  palate,  and  in  such  cases  is  of  yjvat  value  lo 
the  surgeon  if  a  "  flap-sliding"  operation  is  undertaken,  for,  when  the 


premaxilia 


naso-pal.  for. 

palatal  proc.  of  max. 
palatine  foramen, 
palatal  proc.  of  palatine 


Fig.  298. — Showing  the  hard  palate  at  birth.  The  premaxillary 
part  is  formed  from  the  mesial  nasal  processes  ;  the  re- 
mainder by  the  palatal  plates  of  the  maxillary  processes. 

(/■'roni  Keith's  "Human  Embryology  and  Morphology.'1) 

flaps  are  separated  from  the  bone,  they  fall  into  a  horizontal  plane 
and  so  naturally  approach  one  another. 

Development  of  the  premaxilia. — The  premaxillary  bones 
are  ossified  from  two  centres  which  appear  side  by  side  in  the  pre- 
maxillary process  on  the  deep  aspect  of  the  mesial  nasal  process  ; 
later,  these  bifurcate  and  give  origin  to  the  four  incisor  bones. 
(Fig.  298.)  As  a  rule,  all  four  upper  incisor  teeth  are  developed 
on  this  process,  each  bone  forming  the  socket  for  one  tooth  ;  but. 
according  to  Keith,  the  lateral  incisor  may  occasionally  appear  on 
that  part  of  the  alveolus  which  is  developed  from  the  maxillary 
process. 

In  the  majority  of  mammals  the  premaxilia  is  highly  developed 
and  forms  the  prognathion  or  snout.  This  characteristic  is  well 
simulated  in  the  infant  in  those  cases  in  which  a  cleft  in  the  hard 
palate  bifurcates  at  the  naso-palatine  foramen  into  two  branches, 
that    pass    forwards    and    outwards    between    the    premaxillary    and 


126 


FACE.    LIPS.   AND    PALATE 


palatine  processes.     In  sue]  _1ie  prernaxilla,  having  no  lateral 

attachments  to  fix  it.  is  pushed  forward  by  the  palatine  proees- 
they  approach  each  other,  and  at  the  same  time  undergoes  excessive 
development  from  lack  of  restraint  (see  Fig.  305). 


MALFORMATIONS 

MICROSTOMA 

JMacrostonia,  or  buccal  cleft,  is  due  either  to  failure  of  union  of 
the   posterior   portions   of   the    maxillary  and  mandibular  pro 

or,  after  union  has 
taken  place,  to  arrested 
growth  caused  by  the 
pressure  of  amniotic 
bands.  (Fig.  299.)  The 
condition  varies  from 
a  slight  defect  at  the 
angle  of  the  mouth  to 
a  cleft  which  may  ex- 
tend nearly  to  the 
auricle  ;  though  usually 
bilateral,  it  may  be 
unilateral,  and  in  either 
case  is  not  infrequently 
associated  with  other 
congenital  defects,  such 
as  oblique  facial  cleft 
and  accessory  auricles. 
As  usually  seen,  the 
defect  is  limited  to  a 
slight  increase  in  the 
size  of  the  oral  aper- 
ture, and,  beyond  its 
unsightly  appearance, 
gives  rise  to  no  incon- 
venience ;  but  in  severe 
-  -  the  constant  escape  of  saliva,  and  the  defective  nutrition  that 
results  from  the  inability  of  the  child  to  retain  food  in  the  mouth, 
render  an  operation  imperative. 

Treatment. — The  edges  of  the  cleft  should  be  pared  with  a 
sharp  scalpel,  and  then  united  with  an  inner  muco-mucous  layer  of 
catgut  and  an  outer  cutaneous  layer  of  tine  salmon-gut  sutures.  The 
only  detail  requiring  attention  is  the  identification  of  Stenson's  duct 
before  paring  the  edges  of  the  cleft. 


Fig.   299. — Macrostoma  with  auricular 
appendages. 


M  \l  FORMATIONS   OF     i  III     I    \(.l 


A1K  ROSTOMi 

Microstoma,  or  congenital   atr  ita   name   imj 

tIi«'  very  reverse  01    macrostoma.     This   rare  defect    is   the   i"~ult   . . f 
in  excessive  degree  «>i   fusion  between  the  maxillary  and  mandibnlar 

ind   in. iv  take   p]  rach   an   extent    as   to   lea  i 

opening    which    will   only    admil    a    small   probe.    It    must    not    be 
oonfnsed  with  acquired  stenosis  following  cdcatricial  contraction  after 
burns,  syphilitic  ulcera- 
tion, lupus,  etc. 

Treatmen  t. — 
When  necessarv.  the 
oral  aperture  may  be 
elongated  by  incising 
the  cheek  at  the  angles 
of  the  mouth  and 
suturing  the  mucous 
membrane  to  the  skin. 

FACIAL    CLEFT 

This  is  such  a  rare 
malformation  that  a 
ference  to  it 
will  suffice.  As  already 
stated  in  the  account 
of  the  development  of 
the  face,  it  is  due  to 
partial  or  total  failure 
of  union  between  the 
maxillary  process  below 
and  the  lateral  nasal 
and  globular  processes 
above.  Another,  and 
possibly  more  accurate, 
explanation     of    the 

cause  of  facial,  buccal,  mandibular,  and  auricular  clefts  is  offered  by 
Ballantvne,  who  infers  that  they  are  due  to  the  presence  of  amniotic 
adhesions  and  bands  formed  during  morbid  conditions  of  develop- 
ment, rather  than  to  defective  union  of  normal  elements.  The  cleft, 
commencing  in  the  red  margin  of  the  upper  lip  just  externally  to 
the  philtrum,  may  extend  to  the  middle  of  the  lower  eyelid,  thence 
to  the  outer  canthus,  and,  very  rarely,  into  the  temporal  region.  It 
may  be  bilateral  and  asymmetrical,  as  shown  in  Fig.  300,  and  usually 
involves  only  the  soft  pari 


Fig.  300. — Mandibular  cleft  and  two 
varieties  of  facial  cleft. 


128 


FACE,   LIPS.   AND   PALATE 


Treatment. — Simple  clefts  may  be  closed  by  suture  after 
paring  the  edges,  but  clefts  involving  the  orbit  generally  require  a 
complicated  plastic  operation. 

FISTULA   OF    THE   LIP 

The  opening  of  a  fistulous  track,  lined  with  mucous  membrane 
and  directed  upwards  towards  the  ala  of  the  nose,  is  sometimes  seen 
on  the  red  margin  of  the  upper  lip,  close  to  the  philtrum.  Its  presence 
is  probably  due  to  defective  fusion  of  the  soft  parts,  and  serves  to 
emphasize  a  lucky  escape  from  hare-lip.  In  some  instances  similar 
good  fortune  is  shown  in  a  more  definite  manner  by  the  presence  of 
a  well-marked  groove  at  the  site  of  union  of  the  globular  and  maxillary 

processes.  Congenital 
fistula?  of  the  lower  lip 
situated  on  either  side 
of  the  mid-line  have 
also  been  described. 
Their  method  of  form- 
aition  is  obscure. 

Treatment  is 
only  required  if  the 
fistula  gives  rise  to  a 
copious  discharge,  or 
repeatedly  becomes  in- 
flamed from  retention 
of   its    secretion.      In 

„.                tx    TT    ,.,                         r        j-  such   a    case,    one   or 

Fig.  301. — H.   H.   Clutton  s  case  of  median  ..     ,.            , 

hare-lip  and  cleft  alveolus.  more    applications   of 

t       ,     .        Jt  the    galvano  -  cautery 

{This  and  the  next  two  figures,a?r  trout  aiawings  in  i/ie  ° 

Museum  hi  St.  Thomas's  Hospital  Medical  School.)  will  suffice   to   close  it. 


MANDIBULAR    CLEFT 

This  defect  usually  involves  both  the  bone  and  the  soft  parts,  and 
is  situated  in  the  middle  fine  of  the  lower  jaw  at  the  point  where 
the  two  mandibular  processes  should  have  united  (Fig.  300).  It  is  the 
rarest  congenital  malformation  of  the  face,  and  seldom  occurs  alone, 
being  usually  associated  with  various  forms  of  facial  cleft,  or  with 
a  cleft  of  the  tongue  and  the  floor  of  the  mouth. 

Treatment. — The  cleft  may  be  closed  by  one  of  the  methods 
employed  in  the  treatment  of  hare-lip. 

HARE-LIP 

Hare-lip  is  the  commonest  malformation  of  the  face,  and,  according 
to  Stone,  occurs  in  one  out  of  every  2,400  infants.     Though  isolated 


MEDIAN    II  VRE-LIP 


•samples  occur  in  families,  heredity  usually  plays  a  powerful  pari 
in  its  causation,  and  in  Buch  instances  the  tendem 
transmitted  by  the 
mother.  Two  ana- 
tomical varieties  are 
met  with,  the  me- 
dian  and  t  be  lateral. 


M   * 


1 


Fig.  302. — Same  case  as  in  Fig.  301. 


Median  Hare-Lip 

Ollt"  of  the    i 

of  malformations  in 
the  human  being,this 

occurs   as   a   natural 

characteristic  in  the 

animal     from     which 

it  derives  its  name. 

Beinji  due  to  persist- 
ence   of    the    notch 

between     the     two 

globular       processes 

(Kg.     295),    it    can 

never    extend    quite 

to   the  columella   of 

the  nose,  for  this  is 

developed     by     the 

elevation  of  the 

(mesial)  fronto-nasal 
bud.     In  the   classi- 
cal   example     de- 
picted in  Figs.   301 
and    302   it   will   be 
seen  to  involve  the 
lip   for    a  little  less 
than  half  its  depth. 
True  median  hare- 
lip must  not  be  con- 
fused  with    another 
rare    median   defi 
of  the  upper  lip  in 
w  hich  the  cleft, 
though  anatomicallv 
median,   is   embrvo- 
logicallv  clue  to  a  bilateral  hare-lip  complicated  by  an  entire  al 
of   the  lower  end   of  the   fronto-nasal    process   and   the  preniaxillarv 
j 


Fig.  303.  —Median  defect  of  upper  lip  due  to 
imperfect  development  of  the  premaxilla. 


130 


FACE,   LIPS,   AND   PALATE 


bone.  In  such  a  case  the  nose  is  extremely  flattened  owing  to 
absence  of  the  columella  and  the  lower  end  of  the  nasal  septum, 
and  for  the  same  reason  its  alse  form  the  anterior  boundary  of  an 
oro-nasal  cavity  (Fig.  303). 

Treatment. — In  slight  cases  the  defect  is  readily  corrected  by 
Nelaton's  operation  (p.  138),  but  when  the  cleft  is  at  all  deep  the 
methods  advocated  by  Rose  (p.  138)  or  Mirault  (p.  139)  give  the  best 
result. 

Lateral  Hare-Lip 

This,  the  most  usual  form  of  hare-lip,  may  be  unilateral  or  bilateral, 
may  involve  the  soft  parts  only,  or  be  complicated  by  a  cleft  alveolus 
or  complete  cleft  palate.  The  defect  is  more  common  in  boys  than 
in  girls  ;  when  unilateral,  it  occurs  more  often  on  the  left  side,  and 
may  be  accompanied  by  cleft  alveolus  or  cleft  palate,  while  the 
bilateral  variety  rarely  occurs  without  a  corresponding  cleft  in  the 
alveolus  and  palate.  In  both  varieties  the  defect  varies  from  a  slight 
indentation  in  the  red  margin  of  the  lip  to  a  deep  fissure  which 
extends  into  the  nostril. 

In  the  slighter  grades  a  narrow  shining  strip  of  skin  having  the 
appearance  of  scar  tissue  is  sometimes  seen  extending  between  the 
anex  of  the  indentation  and  the  nostril.  As  microscopical  examination 
has  proved  that  none  of  the  elements  of  scar  tissue  are  present  in 

these  strips,  their  appearance  can  only 
be  accounted  for  by  the  disturbance 
in  the  normal  process  of  development 
and  by  delayed  union. 

Unilateral,  or  single  hare- 
lip as  it  is  generally  called,  is  un 
fortunately  more  often  a  deep  than  a 
shallow  cleft,  only  separated  from  the 
nostril  by  a  narrow  strip  of  skin  re- 
presenting the  remains  of  the  upper 
lip.  When  the  fissure  extends  com- 
pletely into  the  nostril  the  alveolus 
is  invariably  cleft  as  well,  and  not 
infrequently  the  defect  in  it  extends 
backwards  into  the  hard  and  soft 
palates. 

The  margins  of  the  cleft  are  often 
unequal  in  length,  and  the  nostril  of 
the  same  side  is  broadened  and  flat- 
tened.    When  the  cleft  extends  into  the  nose  the  flattening  is  more 
marked,  and  frequently  the   outer  margin  of  the  fissure  is  directly 


Fig.  304. — Unilateral  complete 
hare-lip,  showing  forward 
and  outward  rotation  of 
the  premaxilla  and  flat- 
tening of  the  ala  nasi. 

(From  a  patient  at  the  Evelina  Hospital.) 


BILATERAL    HARE-LIP 


131 


continuous  with  the  ;ilu  nasi.  The  deformity  ia  farther  increased  bj 
the  presence  of  a  cleft  in  the  alveolus,  Eor  in  such  cases  the  inner 
<>r  premaxillary  portion  of  the  bone  projects  forwards  in  advance  ol 
the  outer  margin  of  the  cleft,  and.  owing  to  the  loss  of  its  lateral 
attachment,  looks  obliquely  upwards  and  towards  the  unaffected 

the  apex   of  the   nose  and    the  root    of    the   columella   are    carried   with 

it.  and  the  ala  nasi  forms  a  flat  and  almost,  tense  band  of  tissue 
bridging  over  the  upper  extremity  of  the  cleft  (Kip.  304). 

Bilateral  hare-lip,  like  the  unilateral  form,  may  lie  partial 
or  complete,  but  more  often  the  cleft  on  one  side  is  partial,  involving 
only  a  portion  of  the  lip,  and  on  the  opposite  side  is  total,  extending 


i 


■ 


Fig.  305. — Bilateral  complete  hare-lip.     The  profile  shows 
protrusion  and  upward  rotation  of  the  premaxilla. 


through  the  whole  depth  of  the  lip,  and  generally  through  the  alveolus 
and  the  hard  and  soft  palates  as  well.  When  the  clefts  are  total  on 
both  sides  and  extend  to  the  bone,  the  premaxilla  or  os  incisivum. 
no  longer  kept  in  position  by  its  lateral  attachments  to  the  haul 
palate,  is  pushed  forwards  and  upwards  by  excessive  growth  of  that 
part  of  the  nasal  septum  formed  from  the  premaxillary  process,  and 
in  severe  cases  projects  beyond  the  tip  of  the  nose,  giving  the  child 
the  characteristic  prognathous  appearance  (Fig.  305).  Frequently  the 
pedicle  by  which  the  premaxilla  is  attached  to  the  nasal  septum  is  so 
narrow  that  considerable  lateral  movement  of  the  process  is  permitted. 
The  skin  and  subcutaneous  tissue  corresponding  to  the  median  por- 
tion (philtrum)  of  the  upper  Up  is  smaller  than  usual  and  possesses 
no  lower  free  margin,  being  firmly  attached  to  the  subjacent  bone,  and 


i32  FACE,   LIPS,   AND   PALATE 

blending  laterally  and  below  with  the  mucous  membrane  enveloping 
the  premaxilla.  The  nose  is  flattened,  and  the  antero-posterior 
length  of  its  columella  is  shortened  in  proportion  to  the  degree  of 
projection  of  the  premaxilla.  The  teeth  of  the  premaxilla  are  liable 
to  many  variations  from  the  normal ;  they  are  generally  irregular  in 
position  and  obliquely  directed  ;  in  the  majority  of  cases  only  two,  the 
central  incisors,  are  present,  but  occasionally  there  are  four  or  more. 
Site  of  the  cleft. — In  true  median  hare-lip  the  cleft  lies 
between  the  two  globular  processes,  outgrowths  of  the  mesial  nasal 
process,  while  in  lateral  hare-lip  it  is  placed  between  the  globular 
process  on  the  inner  side  and  the  maxillary  process  on  the  outer  side 
— not  between  the  globular  process  and  the  lateral  nasal  process,  as 
suggested  by  Albrecht,  for  it  is  now  well  known  that  the  latter  process 
takes  no  part  in  the  formation  of  the  lip.  The  much-discussed  position 
of  the  cleft  in  the  alveolus  is  described  under  Cleft  Palate  (p.  146). 

Treatment  of  Hare-Lip 

Obviously  the  only  method  of  treating  such  an  unsightly  defect 
•is  by  an  operative  procedure,  having  for  its  object  the  closure  of 
the  cleft  and  the  restoration  of  the  red  margin  of  the  lip.  The  only 
detail  on  which  opinions  have  differed  is  the  age  at  which  the 
operation  should  be  performed.  This  depends  to  a  certain 
extent  (1)  upon  the  size  and  nature  of  the  defect  and  the  condition 
of  the  child,  and  (2)  upon  the  skill  of  the  operator,  the  rapidity 
with  which  he  works,  and  his  familiarity  with  the  method  he  pro- 
poses to  employ.  No  surgeon  should  approach  the  task  in  a  light- 
hearted  manner,  for,  no  matter  how  slight  the  defect,  its  accurate 
closure  requires  a  certain  degree  of  skill  only  to  be  acquired  by 
practice,  as  the  tyro  will  readily  confess  when  he  sees  the  result  of 
his  work,  six  months  or  a  year  later.  Speaking  generally,  the  best 
time  for  operation  is  during  the  second  month,  for  by  then  the  infant 
has  become  accustomed  to  its  nurse,  is  familiar  with  its  surroundings, 
sleeps  for  the  greater  part  of  the  day,  and,  in  the  event  of  the  size 
of  the  cleft  or  the  condition  of  the  mother  having  rendered  bottle  or 
spoon  feeding  necessary,  should  be  free  from  gastro-intestinal  dis- 
turbances. But  if  the  child  is  undeveloped  or  badly  nourished,  the 
operation  must  be  postponed  until  the  patient's  condition  has  materi- 
ally improved,  for  the  mere  remedy  of  the  defect  at  an  early  age  is 
unlikely  to  have  a  marked  effect  upon  its  general  health. 

In  slight  cases  the  child  can  generally  suckle  without  difficulty, 
so  that  if  the  mother  can  nurse  it  properly  it  is  wiser  to  defer  the 
operation  until  the  time  for  weaning  arrives ;  for,  if  the  lip  is  sutured 
at  an  earlier  date,  lactation  is  necessarily  interfered  with  for  at  least 
a   week,   and  may  have  to   be  discontinued   altogether.     When  the 


TREATMENT  OF    HARE-LIP 

cleft  is  large,  natural  feeding  can,  and  Bhould,  be  carried  out  b    i 
of  a  glass  nipple-shield  to  which  is  fitted  a  large  rubber  teal  thai  nil 
the  gap  in  the  lip.     After  the  operation  the  child  should  still   be  fed 
with  maternal  milk,  drawn  off  with  a  pump,  until  such  time  ae  it  can 
be  [nit  to  t  he  breasl  again. 

In  cases  of  bilateral  cleft,  natural  Eeeding  is,  "I'  course,  Impossible. 
In  such  circumstances  the  child  must  lie  Bpoon-fed, and  operated  npon 
as  soon  as  the  Burgeon  judges  that  its  condition  will  permil  ;  after- 
wards it  can  be  brought  up  on  the  bottle  in  the  usual  manner. 
Another  reason  for  operating  on  bilateral  hare-lip  at  an  early 
the  urgent  necessity  of  replacing  the  premaxilla,  and  counteracting 
its  forward  growth  by  the  pressure  which  is  brought  to  bear  upon 
it  by  the  united  lip.  It  is  surprising  wdiat  a  marked  effect  this  pro- 
cedure has  in  inhibiting  the  prognathic  tendency,  especially  if  the 
mother  or  nurse  be  instructed  to  assist  it  by  frequently  and  regularly 
applying  pressure  until  the  protrusion  is  reduced. 

When  hare-lip  coexists  with  cleft  palate,  and  when  the  early 
operation  upon  the  palate  (Lane's  or  Brophy's)  is  contemplated, 
the  closure  of  the  gap  in  the  lip  must  be  deferred"  until  healing 
of  the  palate  is  complete.  As  the  ultimate  appearance  of  the  lip  will 
depend  in  great  measure  upon  the  neatness  of  the  scar,  it  is  of  the 
utmost  importance  that  primary  union  should  be  secured.  In  order 
to  attain  this  desirable  end,  no  operation  should  be  undertaken  until 
the  child  is  in  a  satisfactory  state  of  health,  and  the  mouth,  the  nose, 
and  the  aural  cavities  have  been  examined  and  found  to  be  free  from 
any  septic  condition. 

Preparation  for  the  operation. — When  the  surgeon  has 
to  deal  with  a  healthy,  well-nourished  infant,  no  special  preparation 
is  necessary,  other  than  the  administration  of  a  small  dose  of  castor 
oil  twTo  days  beforehand  ;  in  fact,  the  less  the  normal  routine  and 
surroundings  of  the  child  are  disturbed,  the  better  it  will  bear  the 
operation.  But  wdien  the  infant  is  peevish,  ill-nourished,  and  the 
subject  of  gastro-intestinal  catarrh  from  improper  feeding,  the  opera- 
tion may  have  to  be  delayed  for  a  month  or  longer.  If  the  child  is 
being  suckled  and  does  not  thrive  as  well  as  it  should  do,  it  must 
either  be  weaned  at  once  or  its  nourishment  augmented  by  two  or 
more  bottle-feeds  daily.  Though  the  quality  and  quantity  of  a  feed 
must  be  varied  to  a  slight  extent  for  different  babies,  the  following 
formula  is  a  very  useful  one  on  which  to  base  its  composition  : — 

At  two  months 

Milk 

Whey 

Cream  ........ 

Sugar  ........ 


i34  FACE,   LIPS,   AND   PALATE 

The  addition  of  cream  is  important  as  a  fattening  agent,  and  Barbadoes 
sugar  is  preferable  to  the  Demerara  or  crystallized  variety  on  account 
of  its  better  laxative  properties.  The  milk  should  be  sterilized  or 
pasteurized  as  a  routine,  for  it  is  practically  impossible  to  obtain 
bacteriologically  pure  milk,  no  matter  how  healthy  the  cow  or  how 
carefully  the  milk  is  collected  and  conveyed.  The  addition  of  sodium 
citrate,  in  the  proportion  of  one  grain  to  the  ounce  of  milk,  is  often 
of  great  assistance  in  diminishing  the  size  of  the  curd  and  rendering 
the  milk  more  digestible.  Patent  foods  and  tinned  milks  should 
never  be  given.  The  child's  condition  can  always  be  greatly  improved 
by  daily  inunction  with  cod-liver  oil  after  a  warm  bath,  the  unpleasant 
odour  and  greasy  nature  of  the  oil  being  compensated  for  by  its 
beneficial  effect.  The  room  in  which  the  operation  is  performed  should 
be  well  heated,  and  the  infant  should  be  well  wrapped  up.  Young 
babies  being  very  susceptible  to  shock,  every  precaution  should  be 
taken  to  guard  against  it. 

Position  of  the  patient. — The  position  of  the  infant  during 
operation  depends  mainly  on  the  individual  habit  of  the  operator  : 
some  prefer  the  upright  position,  the  child  then  being  wrapped  in  a 
blanket,  with  the  arms  and  legs  secured,  and  seated  on  a  firm  cushion 
placed  upon  the  nurse's  lap  ;  others  go  to  the  opposite  extreme  and 
favour  the  supine  position  with  the  head  hanging  over  the  end  of  the 
table.  As  a  matter  of  fact,  any  position  will  do,  provided  it  be  so 
arranged  that  blood  cannot  trickle  into  the  pharynx.  Perhaps  the 
most  satisfactory  position  is  a  semi-reclining  one,  with  the  head  tilted 
to  one  side  and  steadied  by  an  assistant  so  that  blood  can  readily 
escape  and  the  surgeon  can  obtain  a  good  view  of  the  lip. 

The  operation. — In  order  to  avoid  repetition,  the  general 
principles  of  the  operation  will  be  described  first,  and  later  a  few  of 
the  most  useful  and  practical  methods  of  closing  the  defect  will  be 
given.  For  a  full  account  of  the  numerous  methods  and  modifications 
that  have  been  suggested  and  employed,  the  reader  is  referred  to  a 
manual  of  operative  surgery. 

The  choice  of  the  anaesthetic  naturally  depends  upon  the  anaesthe- 
tist, but,  as  a  general  rule,  chloroform,  given  on  a  mask  to  commence 
with,  and  continued  with  a  Junker's  inhaler,  is  very  satisfactory  pro- 
vided that  special  care  be  taken  not  to  push  the  anaesthesia  beyond 
the  "  contracted-pupil "  stage.  The  operation  should  never  be  per- 
formed without  an  anaesthetic.  Before  it  is  begun,  the  nose  and  mouth 
should  be  cleared  of  mucus,  and  the  lips  washed  with  ether  soap. 

The  main  principles  that  underlie  a  successful  and  ornamental 
issue  are  (1)  the  free  liberation  of  the  lip,  the  cheek,  the  ala  of  the 
nose,  and  occasionally  of  its  columella,  from  the  underlying  bone  ; 
(2)  the  shaping  of  the  nostril  ;    (3)  the  paring  of  the  margins  of  the 


OPERATION  FOR   hakim. II'  135 

olefl  01  the  cutting  <>f  a  good-sized  flap  «>r  Haps;    (4)  the  accurate 
suturing  of  the  raw  surfaces. 

1.  Tlu'/nr  liberation  of  the  lip  is  the  firsl  and  most  important  step 
in  the  operation,  for  unless  this  be  thoroughly  and  systematically 
earned  nut,  coaptation  without  tension  will  be  impossible.  In  uni- 
lateral cases  the  lip  on  the  outer  side  of  the  cleft  should  be  1 
with  the  lingers,  and  the  mucous  membrane  divided  with  B  sharp 
knife  at  its  junction  with  the  gum.  The  handle  of  the  scalpel  is  then 
used  to  detach  the  lip  and  cheek  from  the  bone,  care  being  taken  to 
stop  the  dissection  short  of  the  infra-orbital  foramen  lest  the  infra- 
orbital nerve  be  damaged.  If  the  ala  of  the  nose  is  flattened  in  the 
slightest  degree,  it  must  be  freed  from  the  subjacent  bone  at  the  same 
time.  Provided  the  tissues  are  torn  and  not  cut  from  the  maxilla, 
the  haemorrhage  is  very  slight  and  can  easily  be  controlled  by  pressure. 
When  the  outer  portion  of  the  lip  has  been  sufficiently  mobilized,  the 
inner  margin  and  the  columella  of  the  nose,  if  at  all  displaced,  are 
freed  in  a  similar  manner. 

2.  The  next  step  consists  in  so  shaping  the  nostril  as  to  make  it 

harmonize  with  that  of  the  opposite  side.     Needless  to  say,  this  is 

only  necessary  when  the  hare-lip  is  a  complete  one,  as  the  contour 

of  the  nose  is  seldom  altered  in  the  partial  variety.     To  commence 

with,  a  straight,  sharp  needle  threaded  with  a  salmon-gut  suture  is 

entered  at  the  lower  end  of  the  naso-labial  groove,  and  carried  inwards 

and  downwards  to  emerge  at  the  junction  of  the  nostril  with  the  outer 

margin  of  the  cleft.     It  is  then  passed  in  an  upward  direction  from 

the  inner  margin  of  the  cleft,  through  the  base  of  the  nasal  septum, 

into  the  opposite  nostril.     The  parts  are  now  approximated,  and,  if 

the  deformity  has  been  properly  corrected,  the  ends  of  the  suture  are 

secured  with  split  shot  after  the  edges  of  the  lip  have  been  pared. 

In  many  cases  this  simple  procedure  produces  the 

desired  result,  but  occasionally  the  cartilage  of  the 

ala   becomes  so   folded  upon  itself  as    partially  to 

block  the  aperture.     In  such  cases  a  large  V-shaped 

piece  may  be  excised,  as  depicted  in  Fig.  306,  or  a 

flap  of   mucous  membrane   can   be  turned  up   and  p-     ong 

the  redundant  cartilage  bodily  removed ;  or  a  por-     Method  of  rec- 

tion  of  the  ala  may  be  excised  (by  an  incision  that     tifying  infolded 

follows   the  naso-labial  groove),  and  re-attached  to     a'a  Dv  excision 

the  lip  and  cheek  with  a  few  fine  sutures.     Though     °.       "?    ape 
.        r    ._  .     ,         ,  °.       piece  of  mucous 

the    rectification    of    the    ala    nasi    appears    simple     membrane   and 

enough    in    theory,    in   practice   a   perfect    result    is  cartilage. 

seldom  obtained. 

3.  The  paring   of  the   margins  of  the  cleft  or  the  shaping  of  flaps 
is  accomplished  with    a    pointed,    sharp,   narrow-bladed    scalpel,    in 


136  FACE,   LIPS,   AND   PALATE 

preference  to  a  tenotome,  which  is  either  unduly  pliant  or  unneces- 
sarily thick  in  the  back.  The  red  border  of  the  lip  being  seized  with 
fine  rat-tooth  forceps  at  the  point  where  its  horizontal  portion  merges 
into  the  vertical  border  of  the  cleft,  the  scalpel  is  entered  exactly  at 
the  junction  of  the  skin  and  mucous  membrane,  plunged  through 
the  whole  thickness  of  the  lip,  and  carried  with  a  gentle  sawing  motion 
upwards  towards  the  nostril,  or  even  into  it  if  necessary.  The  incision 
should  be  kept  just  external  to  the  vermilion  border  of  the  lip,  and 
should  never  be  allowed  to  encroach  upon  it,  otherwise  when  the 
operation  is  completed  the  result  will  be  marred  by  the  presence  of  a 
patch  of  red  mucous  membrane  in  the  line  of  the  scar. 

If  the  operator  intends  to  turn  down  two  flaps  of  mucous  membrane, 
as  in  Fig.  308,  it  is  of  the  utmost  importance  that  the  incision,  at  its 
lower  end,  should  lie  exactly  between  the  mucous  membrane  and  the 
skin,  otherwise  the  vermilion  border  of  the  lip  will  be  interrupted 
by  a  white  line  formed  by  the  included  skin.  In  some  cases  it  may 
be  necessary  to  deepen  the  lip.  This  is  accomplished  by  curving 
the  upper  part  of  the  incision  outwards  well  into  the  skin,  so  that 
the  raw  surface  presents  a  concavity  towards  the  cleft,  as  in  Fig.  308 ; 
but  at  its  lower  extremity  it  must  still  follow  the  junction  of  the 
mucous  membrane  and  the  skin,  or  the  unsightly  patch  of  skin  will 
again  appear  in  the  vermilion  border.  The  haemorrhage  that  follows 
division  of  the  coronary  arteries  in  the  margin  of  the  lip  is  controlled 
temporarily  either  by  an  assistant  seizing  the  lip  between  his  fingers 
or  with  a  pair  of  narrow-bladed  artery  forceps,  and  permanently 
when  the  sutures  are  inserted. 

In  cases  of  bilateral  hare-lip  the  alse  nasi  and  the  lips  are 
thoroughly  freed,  and  the  edges  of  the  latter  denuded  or  shaped  into 
flaps  in  the  manner  already  described.  The  suture  that  was  employed 
for  restoring  the  shape  of  the  nostril  in  the  unilateral  case  should 
perforate  the  base  of  the  nasal  septum  as  before,  and  then  be  passed 
through  the  nostril  from  within  outwards,  and  made  to  emerge  at  a 
point  in  the  naso-labial  groove  exactly  corresponding  to  its  point  of 
entry  on  the  opposite  side.  Before  "cutting  the  labial  flaps,  it  is 
advisable  to  freshen  the  edges  of  the  skin  covering  the  premaxilla  in 
order  to  obtain  a  better  idea  of  the  size  and  thickness  of  the  flaps 
necessary  effectively  to  close  the  defect.  As  it  is  important  to  pre- 
serve as  much  of  this  premaxillary  tab  of  skin  as  possible,  and  also  to 
shape  it  in  such  a  way  that  it  will  dovetail  nicely  between  the  labial 
flaps,  its  inferior  margin  should  be  cut  to  resemble  a  wide  V  (Fig.  314). 
If  the  premaxilla  is  unduly  prominent,  it  should  be  returned  to  its 
normal  position  at  the  same  time,  either  by  simply  pushing  it  back  or, 
if  this  is  not  successful,  by  the  operative  procedure  described  later. 
4.  The  fourth  and  last  stage  of  the  operation  consists  of  so  suturing 


OPERATION    FOR    HARE-LIP 

the  ran-  surfaces  thai  the  edges  of  the  vermilion  border  are  brought  into 
accurate  apposition  and  form  a  continuous  line.  To  '>l>t;iin  this  desir- 
able end,  ilic  first  suture  should  entei  the  lip  exactly  a1  the  junction 
of  its  red  border  with  the  skin  on  one  side,  and  emerge  a1  a  corre- 
sponding point  on  the  opposite  side.  When  the  method  of  closing  the 
defecl  depends  upon  apposition  of  two  inverted  flaps,  as  in  Pig 
it  is  important  to  see  that  they  project  below  the  margin  of  the  lip 
in  the  form  of  a  well-marked  papilla,  otherwise  the  cicatricial  con- 
traction that  follows  healing  will  leave  an  unsightly  noted  in  the  red 
margin.  The  remaining  sutures  are,  then  passed  deeply  into  the  sub- 
Stance  of  the  lip,  but  they  must  not  penetrate,  the  mucous  membrane. 
Finally,  the  whole  lip  is  everted  and  the  mucous  membrane  on  its 
deep  aspect  is  united  by  a  few  fine  sutures.  Fine  silkworm-gut, 
technically  designated  "ophthalmic,"  forms  the  best  suture  material, 
being  pliant,  non-irritating,  and  easily  removable.  Hare-lip  pins  are 
now  obsolete. 

Dressing  the  wound. — In  ordinary  circumstances  the  wound 
is  better  left  uncovered,  so  that  it  may  be  frequently  and  easily 
cleaned  with  a  damp  sponge.  The  doubtful  advantages  that  accrue 
from  the  use  of  a  strip  of  gauze,  soaked  in  collodion  or  Whitehead's 
varnish,  and  fixed  by  a  dumb-bell-shaped  piece  of  strapping  so  applied 
as  to  relieve  tension,  are  neutralized  by  the  ease  with  which  particles 
of  food,  or  mucus  from  the  nose  and  mouth,  collect  beneath  the 
dressing  and  infect  the  wound.  Before  the  child  leaves  the  operating 
table,  the  depression  beneath  the  lower  lip  should  be  well  painted 
with  thick  collodion.  This,  by  contracting  as  it  dries,  produces  an 
amount  of  e version  of  the  lip  just  sufficient  to  leave  an  airway  into 
the  mouth  and  so  minimize  the  danger  of  asphyxiation,  for,  imme- 
diately after  closing  the  cleft,  the  upper  lip  is  somewhat  tightly 
stretched  across  the  alveolus,  possesses  little  if  any  movement,  and, 
by  the  increase  in  its  depth  (i.e.  height),  is  in  close  contact  with  the 
floppy,  redundant  lower  lip,  which  is  sucked  against  it  at  every 
inspiration  until  consciousness  returns. 

After-treatment. — For  the  first  few  days  after  the  operation 
the  child  must  be  nursed  and  coaxed  as  much  as  possible  in  order 
to  reduce  the  amount  of  its  crying  to  a  minimum,  otherwise  some, 
or  possibly  all,  of  the  sutures  may  tear  out.  In  the  event  of  such  a 
catastrophe,  the  surgeon  must  wait  until  the  raw  surfaces  are  covered 
with  healthy  granulations,  and  then  readjust  them  with  the  aid  of 
sutures  and  adhesive  strapping.  Feeding  is  best  carried  out  with 
a  small  spoon,  or  a  drinking-cup  provided  with  a  long  piece  of  india- 
rubber  tubing,  until  such  time  as  the  child  can  be  put  to  the  breast 
again.  In  cases  of  incomplete  cleft  of  slight  degree  this  m 
permissible  in  three  or  four  days,  but  in  the  severer  grades  eight 


138 


FACE,   LIPS,   AND   PALATE 


to  ten  days  must  elapse  before  suckling  can  be  allowed  with  safety. 
The  stitches  may  be  removed  by  degrees,  commencing  on  the  third 
day,  or  all  may  be  left  until  the  seventh  or  eighth  day.  Either  method 
gives  satisfactory  results,  provided  common  sense  is  employed  in 
carrying  it  out.  When  removing  stitches  it  is  always  advisable  to 
stupefy  the  child  with  chloroform,  lest  a  sudden  movement  or  a  violent 
fit  of  crying  make  the  wound  gape. 

Operations  for  Single  Hare-Lip 
Nelaton's  operation. — As  a  primary  operation  this  method  is 
only  applicable  to  defects  of  very  limited  extent,  and  for  this  reason 
can  seldom  be  employed.     It  is  more  often  of  value  in  correcting  an 


Nelaton's  operation. 


indentation  of  the  lip,  the  result  of  cicatricial  contraction  after  some 
other  form  of  operation  (Fig.  307). 

An  inverted  V-shaped  incision  is  made  through  the  whole  thickness 
of  the  lip  above  and  around  the  margin  of  the  cleft.  The  skin  and 
mucous  membrane  is  then  pulled  downwards  until  the  wound  becomes 
diamond-shaped,  when  its  edges  are  approximated  with  a  few  hori- 
zontally placed  sutures. 

Rose's  operation. — As  this  method  only  yields  good  results 
when  the  two  sides  of  the  cleft  are  more  or  less  symmetrical,  its 
application  is  somewhat  limited.  It  is  described  here  because  it 
illustrates  two  of  the  points  that  were  emphasized  in  discussing  the 
operative  procedure  in  general,  viz.  (1)  that  the  height  of  the  lip  may 
be  increased  by  curving  the  vertical  incisions  outwards,  and  (2)  that 
the  incisions  forming  the  flaps  must  be  placed  exactly  between  the 
skin  and  the  red  border  of  the  lip. 

Two  curved  incisions  with  their  concavities  directed  towards  each 
other  are  carried  from  the  apex  of  the  cleft  to  the   junction  of  the 


HARE-LIP:    ROSE'S   OPERATION 


skin  and  the  red  border  <>f  the  lip,  <>n  each  side,  of  the  d 
(Fig.  308).  The  points  at  which  these  incisions  terminate  must 
be  selected  with  care,  for,  if  they  are  placed  too  far  apart,  the 
"  Cupid's  bow "  curve  of  the  lip  will  be  too  exaggerated  when 
suturing  is  completed;  and  if  they  are  too  close  to  the  margins 
of  the  cleft,  the  red  border  will  be  horizontal  at  the  completion  of 
the  operation,  and  notched  upwards  when  cicatricial  contraction  has 
taken  place.  From  the  termination  of  the  first  incision  a  second 
incision  is  carried  inwards  and  upwards  exactly  between  the  vermilion 
border  and  the  skin,  to  emerge  about  the  middle  of  the  cleft  and 
form  two  long  flaps  of  mucous  membrane.  These  are  inverted,  and 
when  the  raw  surfaces  are  sutured  a  well-marked  projection  is  formed 


Fig.  308. — Rose's  operation. 

at  the  margin  of  the  lip.  If  the  flaps  are  too  long,  the  redundant 
portions  can  always  be  removed  before  suturing  is  completed. 

Mi rau It's  operation.— This  operation  is  employed  when  the  two 
sides  of  the  cleft  are  of  unequal  length,  differently  curved,  or  widely 
divergent.  To  obtain  a  good  result  a  certain  degree  of  mathematical 
accuracy  is  required  in  paring  the  edge  and  shaping  the  flap. 

On  the  more  oblique  side  of  the  cleft  (Fig.  309)  a  point,  a,  is 
selected  at,  or  just  below,  the  centre  of  the  curve ;  a'  represents  a 
point  in  the  normal  line  of  the  lip  perpendicularly  below  a  ;  c  is 
situated  at  the  junction  of  the  horizontal  and  vertical  borders  of 
the  steeper  side  of  the  cleft ;  B  marks  the  termination  of  the  flap 
incision.  The  distance  between  b  and  c  must  equal  the  distance 
between  a  and  a'.  The  oblique  side  of  the  cleft  is  pared  by  the 
concave  incisions  da,  e  a,  leaving  a  projection  at  a.  On  the 
opposite  side,  a  flap  bdc  is  formed.  This  is  turned  down  and 
applied  to  the  raw  surface  opposite,  so  that  the  projection  at  A 
fits  into  the  angle  formed  at  b.     The  redundant  tissue  at  the  apex 


i4o 


FACE,    LIPS,   AND   PALATH 


of  the  flap  b  D  c  is  re- 
moved by  an  oblique  in- 
cision  so  placed  that  the 
edges  of  the  red  border 
come  into  accurate  ap- 
position. This  incision 
should  not  be  made  until 
the  flap  has  been  laid  in 
position. 

Edmund  Owen's 
operation,  though  re- 
sembling that  of  Mirault 
to  a  certain  extent,  differs 
from  it  materially  in  that 
the  flap  which  is  brought 
across  the  fissure  is  large 
and  fleshy  instead  of  thin 
and  attenuated.  The  me- 
thod is  particularly  ap- 
plicable to  the  closure  of 
large  and  deep  clefts  with 
asymmetrical  sides,  and  in 
good  hands  gives  most 
excellent  results. 

The  mucous  membrane 
on  the  smaller  side  of  the 
cleft  and  lip  is  removed 
nearly  as  far  as  the  angle 
of  the  mouth  (Fig.  310). 
On  the  opposite  side  a 
large  flap  is  cut,  with  its 
apex  at  the  top  of  the 
cleft.  The  incision  by 
which  this  flap  is  formed 
is.  near  its  extremity,  car- 
ried parallel  to  the  normal 
line  of  the  lip  for  a  short 
distance,  so  as  to  diminish 
the  tendency  to  puckering 
that  takes  place  at  this 
point  when  the  sutures  are 
inserted.  The  large  flap 
thus  formed  is  then  turned 
down,  forming  the  mucous 


HARE-LIP:    OWEN'S   OPERATION 


1  |i 


border  of  the  restored  lip,  and  the  raw  surface  on  the  opp< 
of  the  clefl   is  adjusted    in   such  a  way  thai   it    fits  into  the 
made  by  the  inversion  of  the  flap.    The  direction  of  thi  ihown 

in   Pig.  311. 

To   obtain    a    good   cosmetic    result   in   this,   as   in  every  other 


Fig.  310. — Edmund  Owen's 
operation.  Mucous  mem- 
brane removed  from  whole 
length  of  outer  margin  of 
cleft  :  large  thick  flap  cut 
from  inner  margin. 


Fig.  311. — Edmund  Owen's 
operation.  Flap  from 
left  side  adjusted  along 
right  half  of  lip. 

{This  and  the  preceding  figure  arc 
from   Owen's   "Cleft   Palate    and 

1 1  arc-Lip.') 


operation  for  hare-lip,  it  is  essential  that  the  lip  and  cheeks  be  freely 
separated   from  the  underlying  bone.     "  The  great  advantage  of  this 
method,"   to    quote    Owen,    "is    that    the    resulting    and    inevitable 
scar   does   not    traverse   the   mucous 
membrane    in    the   line    of   the   scar 
in  the  skin,  but,  being  deflected  out- 
wards,  may    escape    attention    as   it 
gradually  tails  out  to  the  free  border, 
which  it  may  reach  at  a  slight  dis- 
tance from  the  corner  of  the  mouth." 
Rectification  of  the  maxillary  arch. 
— When    one    side    of    the    alveolar 
margin  is  unduly  prominent  and  can- 
not be  reduced  by  pressure,  the  de-    Fig    312>_Showing  method  of 
formity  can   be   corrected   by  a   wire        rectifying  prominent    maxil- 
mattress-suture      inserted      in       the        lary  arch, 
manner   depicted   in   Fig.    312,   after 
dividing  the   bone   at  a   convenient  spot  between   two  tooth-germs. 

Operations  for  Double  Hare-Li p 

When   double   hare-lip  is  complicated  by  an    unduly  prominent 

premaxilla,   the  operation  upon  the  cleft  must  not    be  commenced 

until  the  prognathion  has  been  reduced  or  completely  removed.     The 

opinions  of  surgeons  as  to  the  best  course  to  adopt  have  differed   in 


I42 


FACE,   LIPS,   AND   PALATE 


the  past,  and  doubtless  -will  continue  to  do  so  in  the  future.  When 
the  prognathion  is  ill  developed,  obliquely  directed,  and  rotated 
forwards  at  a  right  angle  to  the  alveolar  margin,  there  can  be  no  two 
opinions  as  to  the  best  course  to  pursue  :  it  should  be  resected,  but 
the  tab  of  skin  covering  it  should  not  be  sacrificed,  for,  small  though 
it  may  be,  it  will  be  of  use  in  the  reconstruction  either  of  the  columella 
or  of  the  lip.  On  the  other  hand,  when  the  premaxilla  is  well  shaped, 
firmly  attached,  and  only  slightly  in  advance  of  the  alveolar  margin, 
it  should  be  preserved  and  utilized  in  closing  the  defect,  for  the  very 
fact  of  attaching  the  margins  of  the  cleft  to  it 
will  prevent  its  becoming  prominent,  and,  if  the 
operation  be  performed  within  the  first  two 
months  of  life,  may  even  lead  to  its  recession 
between  the  maxillae.  It  is  in  the  intermediate 
type  of  this  deformity,  when  it  becomes  neces- 
sary to  fracture  the  vomer  before  the  premaxilla 
can  be  replaced,  that  the  difficulty  in  deciding 
upon  the  best  line  of  treatment  arises.  If  the 
premaxilla  is  preserved,  its  pedicle  must  be  di- 
vided before  it  can  be  forced  into  position,  and 
the  mobility  thus  acquired  may  persist  in  after- 
life, rendering  it  useless  for  mastication,  and  a 
continual  source  of  annoyance  to  its  possessor. 
Again,  as  the  bone  is  replaced  by  rotating  it 
through  the  arc  of  a  circle  the  centre  of  which 
is  at  the  seat  of  fracture  of  the  pedicle,  the  in- 
cisor teeth,  apart  from  their  tendency  to  erupt 
irregularly,  may  also  point  backwards  instead  of 
downwards,  and  so  be  worse  than  useless.  On 
the  other  hand,  if  this  bone  be  removed,  a 
permanent  gap  is  left  in  the  alveolar  margin, 
and  the  width  and  forward  curve  of  the  maxillary  arch  do  not  fully 
develop.  In  consequence,  the  lower  jaw  projects  considerably  in 
advance  of  the  upper,  the  flat,  tense,  reconstructed  upper  lip  is  under- 
hung by  the  well-developed  lower  lip,  and  the  child  starts  life  with  a 
profile  that  is  as  unsightly  as  it  is  characteristic  (Fig.  313).  Therefore, 
taking  everything  into  consideration,  it  is  of  the  highest  importance 
to  preserve  this  portion  of  bone  whenever  possible,  for  there  is  always 
the  possibility  of  fibrous  union  taking  place  between  it  and  the 
maxilla? ;  and  even  if,  in  spite  of  this,  the  bone  still  remains  mobile, 
it  can  always  be  excised  after  the  permanent  teeth  have  developed, 
and  the  gap  filled  in  with  an  obturator  fitted  by  a  skilled  dental 
surgeon. 

Operation  for  replacement  of  the  premaxilla  (von  Barde- 


Fig.  313.— Charac- 
teristic profile 
after  excision  of 
the  premaxilla 
and  suture  of 
the  lips.  (Holmes.) 


(  IPERATIONS    FOR    Dorill.K    HARE-LIP 


i  n 


leben's  modification  of  Blandin's  method).  The  muco-periosteum  on 
the  free  edge  <>f  the  oasal  septum  is  incised  in  an  antero  posterioi 
direction  aboul  hali  an  inch  behind  the  premaxilla.  The 
of  the  incision  corresponds  to  the  distance  thai  the  premaxilla 
projects  beyond  the  alveolus.  The  muco-periosteum  is  then  freely 
separated  from  each  side  oi  the  vomer,  and  the  bone  divided  by  a 
vertical  cut  made  with  a  pair  of  scissors.  The  premaxilla  can  now 
be  pushed  back  with  case,  and,  if  necessary,  trimmed  until  it  fits 
into  the  cleft.  Though  it  is  maintained  in  position  by  the  p 
operation  that  is  immediately  performed  upon  the  lip.  it  is  sometimes 


Fig.  314.— Rose's  operation  for  double  hare-lip. 

necessary  to   fix  it  to    the    maxillae  with   a   couple   of  chromicized 
catgut   sutures. 

Operations  for  bilateral  hare-lip.  Rose's  method. — When  the 
premaxillary  bone  is  in  proper  position,  the  skin  over  it  is  freed  and 
pared  laterally  to  resemble  the  letter  V.  Flaps  are  then  cut  from  each 
margin  of  the  cleft,  inverted,  and  sutured  above  to  the  premaxillary 
skin,  and  below  to  each  other,  as  depicted  in  Fig.  314.  In  most  cases 
this  method  yields  an  excellent  cosmetic  result,  but  if  the  upper  Up 
is  shallow  and  skimpy,  or  the  clefts  are  very  wide,  Hagedorn's  method 
is  more  suitable. 

Hagedorn's  method.— After  freshening  the  edges  of  the  skin  over 
the  premaxilla,  as  in  Fig.  315,  a  flap  is  cut  by  the  incisions  1.  2 : 
2,  3,  from  the  outer  margin  of  the  cleft  on  each  side,  with  its  base 
at  the  junction  of  the  horizontal  and  vertical  portions  of  the  vermilion 
border.  These  two  flaps  are  inverted,  and  pulled  upon  so 
straighten  them  out.  An  incision,  1.  a',  is  now  made  downwards  and 
outwards  into  the  lip,  commencing  a  short  distance  above  the  level  of 
the  lateral  angle  a,  on  the  premaxillary  tab  of  skin.  This  incision, 
when  opened  up,  gives   additional  height  to  the  lip  and,  when  the 


Hf 


FACE,   LIPS,   AND   PALATE 


parts  are  approximated,  receives  the  angular  projection  a.  When  the 
suturing  is  completed  as  far  as  the  vermilion  border,  the  redundant 
portions  of  the  flaps  are  removed,  care  being  taken  to  leave  a  pro- 
jection long  enough  to  compensate  for  cicatricial  contraction. 

Summary  of  the  choice  of  operation. — As  no  one 
operation  is  applicable  to  every  variety  of  hare-lip,  and  as  every 
exponent  of  this  particular  branch  of  surgery  is  naturally  biased 
in  favour  of  the  methods  with  which  he  himself  has  obtained  the 
best  results,  the  following  indications,  made  with  due  regard  to  these 
facts,  are  given  as  suggestions  rather  than  as  a  series  of  rules  : — 

1.  Unilateral  //are-lip. — For  partial  clefts  with  ecjual  sides,  employ 
Rose's  method ;  for  partial  clefts  with  unequal  sides,  Mirault's 
method  ;    and  for  complete  clefts,  Edmund  Owen's  method. 


3  3' 

Fig.  315. — Hagedorn's  operation  for  bilateral  hare-lip.  The  unshaded 
part  of  the  margin  of  the  cleft  corresponds  to  the  portion  of  the 
flap  removed  when  suturing  is  nearly  completed. 

2.  Notching  of  the  lip  following  any  of  the  above  operations  may 
be  remedied  by  Nelaton's  operation. 

3.  Bilateral  hare-lip. — For  narrow  clefts,  or  clefts  with  a  large 
premaxilla,  employ  Rose's  method.  For  wide  clefts,  with  uneven 
sides  and  a  small  premaxilla,  employ  Hagedorn's  method. 

CLEFT  PALATE 

Varieties. — Clinically,  two  varieties  of  cleft  palate  are  recog- 
nized— partial,  in  which  the  cleft  is  limited  to  a  portion  or  the  whole 
of  the  soft  palate,  or  to  the  soft  palate  and  a  portion  of  the  hard 
palate  ;  and  total,  when  the  defect  extends  through  the  alveolus  as  well 
as  through  the  hard  and  soft  palates.  The  latter  form  is  frequently 
complicated  by  unilateral  or  bilateral  hare-lip. 

Anatomically,  the  different  varieties  are  classified  with  greater 
accuracy  as  follows  : — 

1.  Tripartite  palate. — The  three  palatal  elements  are  widely 
separated  by  an  elongated  Y-shaped  fissure,  the  limbs  of  which  meet 
at  the  posterior  inferior  angle  of  the  nasal  septum  (Fig.  316).  In 
this  variety  the  central  clement  is  formed  by  the  premaxilla  and  the 


CLEFT    IWLATK 


M5 


Lower  margin  of  the  nasal  septum,  and  the  lateral  element!  l>y  tin- 
alveolar  margin,  tin-  hard  palate,  and  the  soft  palate.  Tripartite 
palate  is  generally   complicated    by  complete   bilateral    hare-lip  and 

aaive  protrusion  of  the  premaxilla. 

2i  Bipartite  -palate. — In  this  variety,  owing  to  the  union  of  the 
premaxilla  with  the  maxilla  on  one  side,  the  cleft  is  single  and  ties 
between  the  premaxilla  and  the  opposite  maxilla,  extending  from 
the  alveolus  to  the  naso-palatine  foramen,  and  posterior  to  this  (in 


m       \ 

J     ■ 

< 

j 

■  1 

Fig.  316. — Tripartite  palate. 


Fig.  317. — Intermaxillary  cleft. 


the  middle  line)  between  the  two  halves  of  the  hard  and  soft  palates 
(Fig.  318).  Theoretically,  the  cleft  should  bend  outwards  in  its  course 
between  the  naso-palatine  foramen  and  the  alveolar  margin,  but  as  a 
matter  of  fact  the  divergence  frcm  the  mid-line  is  very  slight,  as  the 
premaxillary  portion  of  the  alveolar  arch  is  always  rotated  forwards, 
upwards,  and  away  from  the  cleft.  The  maxillary  element  with 
which  the  premaxilla  fails  to  unite  is  usually  the  left  one ;  but  why 
this  should  be,  no  satisfactory  explanation  is  forthcoming.  The 
nasal  septum,  instead  of  being  free,  as  in  the  tripartite  palate,  is 
generally  adherent  for  a  part  or  the  whole  of  its  length  to  the  right 
k 


146 


FACE,   LIPS,   AND   PALATE 


margin  of  the  cleft,  and  in  such  cases  is  also  sharply  deflected  towards 
the  left. 

3.  Intermaxillary  cleft. — As  this  form  of  cleft  is  due  to  failure  of 
union  between  the  palatal  plates,  it  is  situated  in  the  middle  line, 
involves  either  the  soft  palate  alone,  or  both  soft  and  hard  palates, 
and  never  extends  farther  forwards  than  the  naso-palatine  foramen 
(Fig.  317).     Though  the  nasal  septum  may  be  free,  it  is  more  often 

attached  to  the  right  margin  of  the  cleft, 
as  in  the  bipartite  palate. 

4.  Premaxillary  clefts. — One  variety 
of  this  malformation  is  due  to  arrested 
union  between  the  premaxilla  and  the 
maxilla.  The  cleft  extends  from  the 
alveolar  margin  to  the  naso  -  palatine 
foramen ;  posterior  to  this,  the  hard 
and  soft  palates  are  complete  and  well 
formed.  The  cleft,  though  generally 
unilateral,  may  be  bilateral.  The  second 
variety,  a  very  rare  one,  is  associated 
with  median  hare-lip,  the  cleft  lying 
in  the  middle  line  between  the  two 
halves  of  the  premaxilla.  (See  Fig.  302.) 
The  third  form  is  rather  a  gap  in  the 
lip  and  palate  than  a  cleft,  for  it  is  due 
to  suppression  of  the  globular  processes 
from  which  the  philtrum  of  the  lip 
and  the  two  halves  of  the  premaxilla 
are  developed.     (See  Fig.  303.) 

Line  of  the  cleft,  and  re. 
lationship  to  it  of  the  incisor 
teeth. — Because  clinicians  repeatedly 
pointed  out  that  the  cleft  is  usually  situated  between  the  mesial  and 
lateral  incisor  teeth,  Albrecht  formulated  the  theory  that  each  half  of 
the  premaxilla  is  developed  in  two  parts — the  mesial,  with  the  central 
incisor,  from  the  mesial  nasal  process ;  and  the  lateral,  with  the  lateral 
incisor,  from  the  lateral  nasal  process.  Consequently,  he  and  many 
others  believed  that  the  line  of  cleavage  passes  between  these  two 
portions  of  the  premaxilla,  and  not  between  the  premaxilla  and  the 
maxilla.  The  presence  of  a  separate  incisive  bone  for  each  tooth 
strengthened  this  theory.  However,  Kolliker  and  His  have  conclu- 
sively proved  that  the  lateral  nasal  process  takes  no  part  in  the 
formation  of  either  the  premaxilla  or  the  lip,  and  that,  though  an 
incisive  bone  for  each  tooth  is  found,  these  bones  are  not  developed 
separately,  but  are  formed  by  cleavage  of  the  single  ossific  centre  in 


Fig.  318. — Bipartite  palate. 
The  nasal  septum  is  ad- 
herent to  the  right  mar- 
gin of  the  cleft,  and  is 
sharply  deflected  to  the 
left,  forming  a  well- 
marked  "  spur." 

{From  a  case  at  the  Evelina 
Hospital.) 


CLEFT  PALAI  i: 


'  i: 


each  half  of  the  premaxilla  long  after  the  cleft  formation  in  the  paki 
has  taken  place.  (See  under  Development  of  the  Premaxilla.  p,  126.) 
Consequently,  it  is  now  generally  acknowledged  that  the  cleft  passes 
between  the  premaxilla  and  the  maxilla,  or,  in  other  words,  is  ueso- 
exognathic.  The  varying  relationship  of  the  incisor  teeth  to  the 
margins  of  the  cleft  is  thus  explained  by  Arthur  Keith  :  "  The  germ 
of  the  lateral  incisor,  although  carried  by  the  mesial  nasal  process, 
is  laid  down    in   the  cleft  between  the  maxillary  and  premaxillary 


Fig.  319. — Four  specimens  of  cleft  palate,  showing  various  degrees 
in  the  development  of  the  bond  between  the  premaxillary, 
maxillary,  and  lateral  nasal  processes. 

A,  The  bond  or  bridge  of  tissue  crossing  the  cleft  ;  l1,  central  incisor  sac  ;  l2,  lateral  incisor 
sac ;  c,  canine  sac  ;  L,  median  part  of  upper  lip  ;  s,  septum  of  nose. 

(From  Keith's  "  Congenital  Malformations  of  the  Palate.') 

(mesial-nasal)  processes.  In  cases  of  cleft  palate  the  processes  move 
apart  under  the  strain  of  growth  during  the  middle  and  later  months 
of  foetal  life.  Three  fates  may  then  overtake  the  bud  of  the  lateral 
incisor  :  it  may  be  destroyed,  it  may  remain  attached  to  the  pre- 
maxillary process,  but  more  frequently  it  moves  outwards  attached 
to  the  maxillary  process.  I  have  seen  it  stranded  on  the  bridge  of 
tissue  between  the  processes,  or  loosely  attached  at  one  side  of  the 
fissure  or  the  other."     (Fig.  319.) 

Symptoms. — In  early  life  the  patient  is  often  quite  unable  to 


i4«  FACE,    LIPS,   AND   PALATE 

suck  owing  to  its  inability  to  create  a  vacuum  in  the  mouth,  while 
the  attempt  to  swallow  fluids  is  followed  by  their  regurgitation  and 
escape  through  the  nose.  During  the  early  months,  death  may  take 
place  from  malnutrition ;  and  in  addition  there  exists,  at  all  ages,  a 
very  real  danger  from  inflammation  of  the  mucous  membranes  caused 
by  the  lodgment  and  decomposition  of  secretions  and  food-stuffs  in 
the  oro-nasal  cavities.  These  inflammatory  changes  may  set  up 
chronic  nasal  catarrh,  chronic  pharyngitis,  oedema  of  the  mucous 
membrane  of  the  Eustachian  tubes  and  subsequent  deafness,  gastro- 
intestinal disturbances,  bronchitis  and  pneumonia. 

As  age  advances,  the  difficulties  of  deglutition  persist ;  and  when 
speech  commences,  it  is  imperfect,  indistinct,  and  nasal  in  tone. 

The  act  of  phonation  is  in  reality  an  exceedingly  complicated 
process,  demanding  for  its  proper  performance  a  sounding-box  that 
can  be  rendered  air-tight,  and  a  compressing  force.  The  sounding- 
box  is  formed  by  the  bony  walls  of  the  buccal  cavity ;  the  escape 
from  it  of  air  is  prevented  by  the  closure  of  the  lips  and  the  elevation 
of  the  soft  palate ;  and  its  shape  is  altered  by  the  movement  of  the 
tongue  and  cheeks.  The  compressing  force  comes  from  the  chest. 
The  presence  of  a  cleft  in  the  palate  has  little  effect  upon  the  vowel 
sounds,  as  in  enunciating  them  some  of  the  expired  air  is  normally 
allowed  to  pass  through  the  nose,  but  it  interferes  greatly  with  the 
pronunciation  of  the  majority  of  consonants,  for  their  production 
depends  upon  the  complete  closure  of  the  naso-pharynx,  and  the 
more  or  less  sudden  escape  of  compressed  air  from  the  buccal  cavity 
through  the  orifice  of  the  mouth.  Thus  the  letters  D  and  T  are  pro- 
nounced by  allowing  the  compressed  air  to  escape  with  an  explosive 
effect  through  an  opening  between  the  tip  of  the  tongue  and  the 
anterior  part  of  the  hard  palate  ;  the  sibilant  S  is  sounded  by  forcing 
air  through  a  chink  between  the  tongue  and  the  palate  just  behind 
the  incisor  teeth.  In  normal  circumstances  the  naso-pharynx  is 
separated  from  the  oral  pharynx  during  phonation  by  the  elevation 
of  the  soft  palate  until  it  comes  in  contact  with  a  ridge  of  tissue,  the 
ridge  of  Passavant,  formed  on  the  posterior  and  lateral  walls  of 
the  pharynx  by  the  contraction  of  the  superior  constrictor  muscles. 
When  the  palate  is  cleft,  this  closure  cannot  be  effected,  so  that  labial, 
lingual,  and  palatal  consonants  such  as  P,  D,  T,  S,  C,  and  K  cannot 
be  pronounced.  The  subject  of  the  defect  is  by  long  practice  fre- 
quently able  to  overcome  a  few  of  these  difficulties  by  forming  some 
of  the  closed  sounds  in  the  larynx  and  by  making  others  in  a  different 
part  of  the  mouth.  In  this  he  is  often  materially  assisted  by  the 
presence  of  hypertrophied  turbinate  bones  and  adenoids  which  offer 
an  obstacle  to  the  escape  of  air  through  the  nose,  and  in  the  latter 
case  also  add  to  the  projection  formed  by  the  ridge  of  Passavant. 


THE   USE   OF   AN    OBTURATOR  149 

Treatment  of  Cleft  Falate 

The  number  of  cases  in  which  the  partial  or  total  closure  of  the 

cleft  by  suture  cannot  be  attempted  must  be  very  small  indeed,  but 
occasionally  the  surgeon  meets  with  one  in  which  the  gap  is  so  wide 
and  the  available  tissue  so  scanty,  cither  as  a  result  of  the  magnitude 
of  the  deformity  or  of  cicatricial  contraction  after  an  operation  that 
has  failed,  that  he  has  to  consider  seriously  the  advisability  of  having 
a  suitable  obturator  fitted  rather  than  subject  the  child  to  an  opera- 
tive procedure  which,  from  the  nature  of  the  cleft  or  of  the  tissues 
bounding  it,  is  doomed  to  failure  from  the  outset. 

Though  the  use  of  an  obturator  gives  the  best  result  in  connexion 
with  a  cleft  in  the  hard  palate  alone,  its  employment  for  this  purpose 
is  seldom  required,  for  such  clefts  can  nearly  always  be  closed  by 
operation.  At  the  present  time  such  an  instrument  is  rarely  employed, 
and  then  only  for  irremediable  defects  in  the  soft  palate,  when  its 
function  is  to  close  the  naso-pharynx  and  so  improve  a  defective 
articulation.  The  appliance  consists  of  a  dental  plate  (held  in  position 
by  the  permanent  molars),  to  which  is  attached  either  a  soft  elastic 
balloon  (Schlitsky)  that  fills  the  naso-pharynx  and  adapts  itself  to 
the  changes  in  shape  that  occur  therein  during  the  act  of  phonation, 
or  a  flexible  indiarubber  velum  (Moriarty)  that  hangs  down  in  front 
of  the  soft  palate,  and  is  blown  against  the  posterior  wall  of  the 
pharynx  when  the  air  is  compressed  in  the  buccal  cavity.  Except 
in  rare  cases,  when  any  means  are  justified  in  securing  an  improve- 
ment in  phonation  and  deglutition,  mechanical  devices  should  only  be 
used  as  a  complement  to  surgical  treatment. 

Age  at  which  the  operation  should  be  performed. 
— This  important  consideration  has  been,  and  still  is,  the  subject 
of  much  argument.  Surgeons  experienced  in  the  treatment  of 
cleft  palate  may  be  divided  into  two  classes  :  those  who  favour 
operation  within  the  first  three  months  of  life,  and  those  who 
defer  treatment  until  the  third  to  the  sixth  year.  Both  bring 
forward  analogies,  arguments,  and  proofs  in  favour  of  their  conten- 
tions, and  each  school  criticizes  severely  the  methods  advocated  by 
tbe  other.  In  discussing  the  advantages  and  disadvantages  of  the 
early  and  late  operations,  it  should  always  be  remembered  that 
the  cleft  is  only  one  manifestation  of  a  developmental  error  that 
has  involved  not  only  the  soft  parts  but  also  the  bony  walls  of 
the  oral  and  nasal  cavities,  so  that  the  mechanical  closure  of  the 
cleft  at  an  early  age,  no  matter  how  perfect  it  be,  seldom  confers 
upon  the  patient  a  normal  speaking  apparatus.  The  same  considera- 
tion applies  with  even  greater  force  to  the  result  of  the  late 
operation,   for  the  child  who  passes  the  first  few  years   of  his  life 


15°  FACE,   LIPS,   AND   PALATE 

with  a  cleft  palate  cannot  even  be  taught  to  articulate  clearly, 
and  when  the  defect  is  remedied  his  speech  is  so  little  better 
that  the  phonetic  lesson  must  be  commenced  all  over  again. 

The  advocates  of  the  early  operation  close  the  cleft  by  the 
methods  of  Arbuthnot  Lane  or  Brophy  ;  those  who  favour  the  late 
operation  employ  Langenbeck's  method. 

In  order  to  obtain  the  best  phonetic  result,  two  factors  are 
essential:  (1)  that  the  soft  palate  should  be  well  formed  and 
freely  movable,  and  (2)  that  the  child  should  not  have  learned 
to  talk  before  the  closure  of  the  cleft  is  brought  about.  Brophy's 
method  is  the  only  one  that  fulfils  both  these  requirements.  Un- 
fortunately, the  operation  is  a  severe  one,  is  only  applicable  in 
selected  cases,  and  in  some  unsuccessful  ones  has  been  followed  by 
extensive  necrosis  of  the  maxillse  and  sloughing  of  the  soft  parts. 
It  is  owing  to  the  danger  of  necrosis  that  tins  ingenious  operation 
has  not  received  more  general  support  amongst  English  surgeons. 
Arbuthnot  Lane's  method  complies  with  one  of  the  essentials,  in 
that  the  cleft  is  closed  long  before  the  child  commences  to  talk  ; 
but,  owing  to  the  extensive  flaps  that  must  be  fashioned,  the 
resulting  soft  palate  is  seldom  mobile,  and  phonation  suffers  in 
consequence.  Similarly,  Langenbeck's  method  fails  in  one  of  the 
necessary  requirements,  inasmuch  as  it  can  seldom  be  performed 
until  after  speech  has  commenced  ;  but  it  undoubtedly  possesses 
the  great  advantage  of  leaving  the  patient  with  a  well-shaped, 
freely  movable  soft  palate,  which,  so  far  as  the  phonetic  result 
of  the  operation  is  concerned,  is  an  absolute  necessity. 

Taking  these  various  facts  into  consideration,  and  disregarding 
the  ideal  operation  of  Brophy  for  the  reasons  already  mentioned, 
my  opinion  is  that  Langenbeck's  operation,  performed  between  the 
ages  of  tiro  and  three  years,  or  earlier  if  the  size  of  the  cleft  and 
the  thickness  of  the  tissues  permit,  gives  the  best  result  in  the 
majority  of  cases.  Coexisting  hare-lip  should  be  operated  upon  at 
the  age  of  three  months.  When  Lane's  method  is  employed,  how- 
ever, the  treatment  of  the  defect  in  the  lip  should  invariably 
be  deferred  until  some  weeks  after  the  palate  has  been  successfully 
closed. 

Preparation  of  the  patient. — It  is  always  advisable  to 
place  the  patient,  a  week  before  the  operation,  under  the  care  of  the 
nurse  who  is  to  look  after  it,  so  that  it  may  become  accustomed  to 
its  surroundings  and  have  any  irregularities  in  its  diet  corrected.  If 
the  bowels  are  acting  regularly  there  is  no  necessity  to  upset  the  child 
by  administering  an  aperient,  but  if  there  be  constipation  a  small 
dose  of  castor  oil  should  be  given  twenty-four  hours  before  operating. 
When  the  time  comes,  the  child  should  be  warmly  wrapped  up,  and 


CLEFT  PALATE:  THE  EARLY  OPERATION   151 

placed  upon  a  warm-  (not  a  hot-)  water  pillow,  on  a  high  table,  with 
its  head  hanging  over  the  edge,  so  that  the  operator,  who  is  seated, 
may  obtain  a  good  view  of  the  palate.  The  mouth  is  kept  open  with 
two  of  Lane's  spring  gags,  one  on  each  side,  and  the  f;ongue  is  drawn 
forwards  l>y  a  suture  passing  through  its  tip. 

During  the  operation,  sterilized  marine  sponges,  being  soft  and 
highly  absorbent,  are  preferable  to  woollen  swabs  for  mopping  up 
the  blood  and  saliva.  The  only  special  instruments  required  are  : 
two  pairs  of  long  dissecting  forceps,  one  toothed  and  one  plain  ;  one 
stout,  narrow-bladed  scalpel  ;  one  cleft-palate  knife  with  a  long  thin 
handle,  a  narrow  pointed  blade,  and  a  cutting  edge  not  more  than 
a  quarter  of  an  inch  in  length  ;  two  pairs  of  curved  and  bent  ele- 
vators ;  a  pair  of  rectangular  scissors  ;  and  Lane's  needle-holder  and 
cleft-palate  needles.  In  addition  to  the  foregoing,  there  are  required 
for  Brophy's  operation  a  pair  of  large  curved  needles  on  strong 
shafts,  shaped  somewhat  Uke  the  needles  employed  in  the  repair 
of  a   ruptured   perineum. 

Early  operation  for  cleft  palate.— The  advantages  of  the 
^arly  operation  are — 

1.  The  young  infant,  with  lew  exceptions,  is  healthy. 

2.  Its  digestion  has  not  been  impaired  by  experimental  feeding. 

3.  Repair  of  its  tissues  takes  place  with  great  rapidity. 

4.  The  absence  of  teeth  renders  its  mouth  free  from  pathogenic 

and   putrefactive   micro-organisms,    and   so   minimizes   the 
danger  of  sloughing. 

5.  The  absence  of  teeth  also  permits  of  the  fashioning  of  large 

flaps. 

6.  Hemorrhage  is  very  slight,  and  the  vessels,  being  so  small, 

seldom  require  ligation. 

7.  The   baby   seldom   vomits   after  the   anaesthetic,   and  takes 

its  food  with  gusto  within  a  few  hours  of  the  completion 
of  the  operation. 

8.  It  generally  sleeps  for  the  greater  part  of  the  day. 
The  disadvantages  are — 

1.  The  field  of  operation  is  small,  and  the  tissues  are  very  friable. 

2.  The  soft  palate  formed  by  Lane's  method  becomes  a  rigid 

piece  of  cicatricial  tissue  if  the  muscular  layer  is  encroached 

on  when  cutting  the  flaps. 
Brophy's  operation. — The  performance  of  tins  operation  is 
practically  impossible  after  the  third  month,  owing  to  the  ossification 
of  the  maxillae,  and,  according  to  its  originator,  is  best  carried  out 
about  the  third  week.  In  this  country  it  has  the  support  and  approval 
of  no  less  an  authority  than  Edmund  Owen,  who  regards  it  as  the 
ideal  operation  for  cleft  palate.     (Figs.  320  and  321.) 


152 


FACE,   LIPS,   AND   PALATE 


The  subjoined  account  is  taken  from  Brophy's  paper,  read  at  the 
Tliird  International  Dental  Congress,  Paris,  1900  : — 

"  Pare  the  edges  of  the  cleft  and  trim  the  opposing  edges  of  bone  as  well 
it  will  secure  a  sufficient  exudate,  so  essential  to  a  perfect  union,  to  make 


Fig.  320. — Brophy's  operation  :    Sutures  passed. 

the  operation  successful  in  this  respect  at  least.  .  .  .  The  knife,  will  easily  cut 
through  the  soft  bone  of  the  hard  palate  as  well  as  the  alveolar  processes 
of  young  patients.  Then  raise  the  cheek,  and  well  back  toward  the  posterior 
extremity  of  the  hard  palate,  just  back  of  the  malar  process  and  high  enough 
to  escape  all  danger  of  not  being  above  the  palate  bone,  insert  a  large  braided 


Fig.  321. — Brophy's  operation:   Maxillae  forcibly  approximated 
and  sutures  secured  over  lead  buttons. 

silk  suture,  carrying  it  through  the  substance  of  the  bone  to  the  central 
fissure  by  means  of  one  of  the  strong  needles,  with  the  opposite  needle  carrying 
a  corresponding  suture  through  the  opposite  side.  We  then  have  two  silk 
suture  loops  carried  to  the  centre  of  the  cleft,  and  passing  one  loop  through 
the  other  enables  us  to  carry  the  one  loop  through  both  of  the  maxillary 
bones.  The  silk  is  more  easily  introduced  by  the  needle  than  wire,  but  a 
silver  wire  should  always  be  substituted  for  it  and  drawn  through  to  take. 


CLEFT  PALATE:  BROPHY'S  OPERATION    153 

its  place.  Tho  wiro  sliould  bo  No.  20,  and  may  bo  doubled  in  COM  the 
condition  of  the  parts  and  t ho  tension  upon  the  tissues  necessary  to  approxi- 
mate them  seem  to  require  it.  Nearer  the  front  portion  of  the  maxilla  insert 
another  wire,  carrying  it  through  t  ho  substance  of  the  bone  above  the  palatal 
plate,  and  through  the  outer  side  in  a  position  corresponding  to  the  place  of 
entrance.  Thus  we  will  have  one  wire  passing  over  the  palate  in  front  .,1 
the  malar  process  of  the  bone,  and  another  behind  it. 

"Tho  next  step  is  to  make  lead  plates  (No.  17  American  gauge)  to  tit 
the  convexity  of  the  buccal  surface  of  the  bones.  Have  them  provided 
with  eye-holes,  through  which  are  passed  the  protruded  ends  of  the  wire 
on  each  side.  Twist  these  together — that  is,  the  right  end  of  the  posterior 
with  the  right  end  of  the  anterior  wire,  and  the  same  on  the  left  side.  These 
form  heavy  tension  sutures,  and  the  parts  when  once  approximated  by  their 
use  cannot  be  separated,  as  the  sutures  do  not  cub  out.  If  the  cleft  is  a  very 
wide  one  and  we  are  not  able  to  close  it  by  twisting  the  wires  together  upon 
the  lead  plates,  force  may  be  exerted  by  the  thumb  and  fingers,  or  by  means 
of  a  forceps  designed  for  that  purpose.  If  by  such  force  the  edges  of  the 
cleft  do  not  approximate,  then  there  is  a  further  step  to  be  taken  which  will 
obviate  these  difficulties.  After  the  cheek  is  well  raised,  divide  the  mucous 
membrane  and  the  bone  through  the  malar  process.  Carry  the  knife  in  a 
horizontal  direction,  and,  when  well  inserted,  sweep  the  handle  forward  and 
backward.  In  this  way  a  maximum  amount  of  bone  and  a  minimum  amount 
of  mucous  membrane  will  be  divided.  This  done  on  either  side,  the  bone 
can  readily  be  moved  toward  the  median  line.  The  wire  sutures  passing 
through  the  lead  button  may  now  be  again  twisted,  and  the  cleft  of  the  hard 
palate  be  closed  by  approximation  of  the  two  sides.  The  incision  of  the 
mucous  membrane  must  be  made  as  small  as  possible,  as  this  membrane 
must  serve  to  retain  the  bones  in  proximity,  or  to  hold  them  nearly  together. 
If,  after  the  parts  are  approximated,  they  are  kept  antiseptically  clean,  or 
as  nearly  so  as  possible,  they  will  unite  kindly,  and  the  palate  will  be  formed 
so  that  its  full  function  will  be  established.  Separation  of  the  bones  is 
attended  with  very  little  haemorrhage,  and  the  parts  do  not,  as  a  rule,  cause 
more  inconvenience  to  the  patient  than  the  ordinary  operation  of  lifting 
the  hard  palate,  according  to  the  practice  of  Sir  William  Fergusson.  Should 
haemorrhage  require  attention  it  is  easily  controlled  by  the  application  of 
sponges  wrung  out  of  water  at  about  170°  F.  These  hot  sponges,  held  in 
contact  with  the  bleeding  surfaces  a  very  few  minutes,  will  be  all  that  is 
required.  The  germs  of  the  teeth  are  sometimes  disturbed,  and  I  have 
found  occasionally  certain  teeth  imperfectly  developed  when  erupted.  The 
palatal  arch  is  in  some  cases  contracted,  but  this  will  not  be  permanent, 
for,  if  the  operation  is  performed  early  enough,  when  development  is  com- 
plete, the  teeth  of  the  upper  jaw  occlude  naturally  with  those  of  the  lower 
jaw.  It  is  a  well-known  fact  that  the  alveolar  processes  develop  with  the 
teeth,  and  this  seems  to  be  a  pronounced  factor  in  the  formation  of  the  jaw 
and  the  guiding  of  the  teeth  into  their  proper  position.  After  the  approxi- 
mation of  the  edges  in  the  manner  that  I  have  described,  the  parts  should 
be  thoroughly  dried,  the  edges  of  the  cleft  carefully  examined,  and,  if  need 
be,  some  fine  silk  sutures  inserted  here  and  there  to  ensure  the  perfect  co- 
aptation of  the  parts.  These  coaptation  sutures,  formerly  used  by  me  in  the 
closure  of  the  hard  palate  in  young  children,  are  now  seldom  employed." 

'Arbuthnot   Lane's  operation. — As   the   method    now    to    be 
described  aims  at  the  closure  of  the  cleft  by  large  flaps  composed  of 


i54  FACE,   LIPS,   AND   PALATE 

muco-periosteum  in  the  case  of  the  hard  palate,  and  mucous  mem- 
brane and  submucous  tissue  in  the  case  of  the  soft  palate,  it  is  essen- 
tial that  it  be  performed  before  the  milk  teeth  erupt,  or  the  size  of 
the  flaps  will  be  seriously  curtailed.  Though  Lane  advises  the  per- 
formance of  the  operation  within  a  few  days  of  birth,  I  have  found  by 
experience  that  from  six  weeks  to  three  months  is  the  most  suitable 
age.  In  spite  of  the  apparent  severity  of  the  procedure,  haemorrhage 
is  inappreciable  in  amount  and  there  is  little  if  any  shock.  The 
cosmetic  result,  even  with  extensive  clefts,  is  as  good  as  can  be  desired. 
There  are  very  few  clefts  that  cannot  be  closed  at  one  operation,  and, 
what  is  more  important  still,  the  closure  is  permanent.  There  is  only 
one  place  where  gaping  is  liable  to  occur,  and  that  is  at  the  junction 
of  the  hard  and  soft  palates,  but  the  aperture  is  usually  so  small  that 
it  can  easily  be  closed  a  few  weeks  later  by  a  simple  plastic  operation. 

So  excellent  is  the  result  of  this  operation,  as  far  as  it  concerns 
the  closure  of  the  cleft,  that  in  a  series  of  upwards  of  forty  cases, 
operated  upon  between  six  weeks  and  five  months  of  age,  I  am  able 
to  record  only  two  real  failures,  and  in  both  of  these  the  malnutrition 
of  the  infant  was  the  predisposing  factor. 

General  principles  of  the  operation. — The  following  description  is 
quoted  from  Arbuthnot  Lane's  article  on  the  Treatment  of  Cleft 
Palate  in  the  Lancet  of  January  4th,  1908  : — 

"  Practically  the  flap  formation  employed  to  close  in  the  hard  and  soft 
palates  resolves  itself  into  two  methods.  If  the  soft  parts  overlying  the 
edges  of  the  cleft  are  thick  and  vascular,  a  flap  is  cut  from  the  mucous  mem- 
brane, submucous  tissue,  and  periosteum  of  one  side,  having  its  attachment 
or  base  along  the  free  margin  of  the  cleft.  The  palatine  vascular  supply 
(the  great  or  anterior  palatine  artery)  is  divided  while  the  flap  is  being 
reflected  inwards,  and  it  depends  for  its  blood  supply  on  vessels  entering 
its  attached  margin.  The  mucous  membrane,  submucous  tissue,  and 
periosteum  are  raised  from  the  opposing  margin  of  the  cleft  by  an  elevator, 
an  incision  being  made  along  the  length  of  the  edge  of  the  cleft.  The 
reflected  flap,  with  its  scanty  supply  of  blood  derived  from  small  vessels 
in  its  attached  margin,  is  then  placed  beneath  the  elevated  flap,  the  blood 
supply  of  which  is  ample,  and  it  is  fixed  in  position  by  a  double  row  of 
sutures.  In  this  way  two  extensive  raw  surfaces  well  supplied  with  blood 
and  uninfluenced  by  any  tension  whatever  are  retained  in  accurate  apposi- 
tion. If,  on  the  other  hand,  the  cleft  is  too  broad  to  admit  of  its  safe  and 
perfect  closure  in  this  manner,  one  flap,  comprising  all  the  mucous  membrane, 
submucous  tissue,  and  periosteum  on  one  side,  is  raised,  except  at  the  point 
of  entry  of  the  posterior  palatine  vessels,  while  the  soft  parts  on  the  opposite 
side  are  raised  in  a  flap  from  which  the  posterior  palatine  supply  has  been 
excluded,  and  which  turns  on  a  base  formed  by  the  margin  of  the  cleft.  Here 
we  have  a  mobile,  well-vascularized  flap,  which  can  be  thrown  as  a  bridge 
in  any  direction  and  can  be  superimposed  on  the  flap  of  the  opposite  side, 
the  closure  being  necessarily  rendered  complete  by  flaps  from  the  edges  of 
a  hare-lip.  ...  As  time  goes  on,  the  damage  done  to  the  temporary 
teeth   by   the   separation   of   the  superjacent  mucous   membrane   becomes 


CLEFT  PALATE:   LANE'S  OPERATION  id.s 

steadily  greater,  still,  this  La  a  matter  of  do  moment  as  oompared  with  the 
importance  of  the  early  olosure  of  the  oleft,  since  the  milk  teeth  are  often 
unsatisfactory  in  cases  of  cleft  palato,  apart  from  operative  interference, 
while  the  permanent  teeth  escape  damage  from  it  if  undertaken  sufficiently 
early  in  life." 

The  application  of  these  methods  will  now  be  described  briefly  ; 
for  farther  details  the  reader  must  consult  the  original  paper. 

Fig.  322  represents  the  roof  of  an  infant's  mouth  with  a  broad 
oleft  of  nearly  the  whole  -palate,  in  which  the  nasal  septum  occupies 
a  median  position.  The  incision  ab  commences  at  the  anterior  limit 
of  the  cleft,  and  runs  forwards  and  outwards  across  the  alveolus  to 
its  outer  surface.  From  its  termination,  the  incision  BCD  is  made 
to  pass  along  the  outer  side  of  the  alveolus,  and  then  through  the 
mucous  membrane  of  the  soft  palate,  to  terminate  at  the  anterior 
pillar  of  the  fauces.  From  this  point,  d,  a  third  incision  is  made 
along  the  posterior  free  border  of  the  soft  palate  as  far  as  the  tip  of 
the  uvula,  e.  The  flap  abcde  thus  outlined  is  dissected  up,  and 
when  reflected  will  hinge  upon  the  margin  of  the  cleft,  A  E.  The 
anterior  half,  a  b  c,  of  this  flap  consists  of  muco-periosteum.  When 
cutting  it,  care  must  be  taken  not  to  allow  the  portion  reflected  from 
the  alveolus  to  be  too  thick.  The  posterior  half,  c  D  e,  should  consist 
of  mucous  membrane  and  submucous  tissue  only,  and  should  leave 
the  muscles  of  the  soft  palate  exposed,  but  uninjured.  The  reader 
will  now  readily  perceive  the  advantage  that  accrues  from  performing 
this  operation  before  the  teeth  erupt,  for  the  incision  b  c  can  then  be 
made  on  the  outer  side  of  the  alveolus,  and  thereby  the  width  of  the 
flap  increased  by  a  quarter  to  half  an  inch. 

On  the  opposite  side  of  the  cleft,  an  incision,  a  z,  is  carried  forwards 
and  outwards  to  terminate  on  the  alveolus,  as  in  the  diagram,  or 
beyond  it  if  necessary.  A  second  incision,  a  f,  is  then  made  along 
the  margin  of  the  cleft,  and  the  muco-periosteum  between  z,  a,  and  f 
is  raised  from  the  bone.  During  this  procedure  due  care  must  be 
taken  to  avoid  injuring  the  anterior  palatine  artery.  The  point  of 
the  uvula,  h,  is  now  seized  with  toothed  forceps  and  pulled  towards 
the  operator,  so  as  to  expose  the  upper  or  nasal  surface  of  the  soft 
palate.  Along  this  nasal  surface  of  the  soft  palate  an  incision  is  carried 
(through  the  mucous  membrane  and  submucous  tissue  only)  from 
f,  the  point  at  which  the  incision  along  the  margin  of  the  cleft  ter- 
minated, to  g,  just  below  the  posterior  pillar  of  the  fauces.  The  free 
edge  of  the  soft  palate  is  then  incised  from  g  to  h,  as  on  the  opposite 
side.  The  flap  f  g  h,  thus  marked  out,  is  dissected  up  with  a  short- 
bladed  scalpel,  and  reflected  inwards  so  as  to  hinge  upon  its  attached 
margin,  f  h,  at  the  border  of  the  cleft.  The  last  step  consists  in  freeing 
the  nasal  surface  of  the  soft  palate  from  the  posterior  margin  of  the  hard 


156 


FACE,   LIPS,   AND   PALATE 


palate  from  f  to  k.  All  that  now  remains  is  to  take  the  large  flap 
a  b  c  d  e,  turn  it  inwards,  tuck  it  under  the  raised  muco-periosteum 
z  a  f  in  front,  and  cover  it  behind  with  the  flap  f  g  h,  as  in  Fig.  323. 
Sutures  are  then  inserted,  as  shown  in  Fig.  323,  first  along  the  line 
bcd,  uniting  the  free  edge  of  the  reflected  flap  to  the  raised  flap  and 
to  the  raw  surface  on  the  nasal  aspect  of  the  soft  palate  ;  next,  along 
the  line  dhg,  uniting  the  free  edges  of  the  soft  palate  ;  and  lastly,  a 
third  row,  afg,  uniting  the  reflected  flap  to  the  free  edge  of  the  raised 
flap,  a  F,  and  to  the  edge,  f  g,  of  the  flap  that  has  been  turned  inwards 


C    /INT.  PAL.  ART: 


n  D 
G     -  ^H  T  H 

Figs.  322  and  323. — Arbuthnot  Lane's  operation  (see  text). 


from  the  nasal  surface  of  the  soft  palate.  When  the  nasal  septum 
occupies  the  middle  line,  as  in  Fig.  322,  the  reflected  flap  may  be  fixed 
to  it  by  an  additional  row  of  sutures  (a  x,  Fig.  323),  provided  that  the 
mucous  membrane  is  removed  from  the  edge  of  the  septum  and  from 
the  surface  of  the  reflected  flap  along  the  area  of  apposition.  Though 
this  row  of  sutures  is  not  essential,  it  constitutes  a  refinement  which 
gives  additional  security  to,  and  increases  the  blood  supply  of,  the 
reflected  flap. 

The  remaining  diagrams,  illustrating  the  application  of  these 
methods  to  different  varieties  of  clefts,  need  but  a  brief  description, 
as  the  principles  underlying  the  operations  are  the  same  in  every  case. 

Fig.  324  illustrates  a  complete  cleft  in  which  the  nasal  septum  is 
adherent  to  the  right  margin.  The  reflected  flap  should  always  be 
formed  from  the  side  of  the  cleft  to  which  the  septum  is  adherent, 
as  it  obtains  an  additional  supply  of  blood,  from  the  septal  vessels 
at  its  attached  border,  along  the  margin  of  the  cleft.     If  the  cleft  is 


CLEFT  PALATE:  LANES  OPERATION 


i57 


v.tv  wide,  the  raised  flap  rAZ  can  be  converted  into  a  mobile  flap 
by  continuing  the  incision  from  z  to  y,  and  bent  inwards  to  cov«-r  the 
large  reflected  flap  (Fig.  325).  In  raising  tins  flap  the  operator 
must  avoid  carrying  the  dissection  too  far  in  a  backward  direction, 
or  he  will  divide  the  anterior  palatine  artery,  a  vessel  that  must  be 
preserved. 

Figs.  326  and   327  represent  the   method    of   closing   a    cleft  in- 
volving the  soft  palate   and  a   portion   of  the  heard  palate.    The  flap 


Figs.  324  and  325.— These  and  the  six  following  diagrams  illustrate  the 
application  of  Arbuthnot  Lane's  method  to  different  varieties  of 
cleft  {see  text  for  each). 

a  g  h  is  cut  from  the  nasal  surface  of  the  soft  palate,  and  is  then 
reflected  inwards  and  superimposed  upon  the  reflected  flap  abcd,  as 
in  Fig.  327. 

Fig.  328  depicts  a  large  cleft  with  a  mesial  nasal  septum.  If  it  be 
considered  impossible  to  close  this  at  one  operation  by  the  method 
already  described,  it  can  be  closed  in  two  stages  by  another  method. 

First  stage.— Flaps  abcd  and  efgh  are  outlined  and  freed, 
care  being  taken  to  avoid  injuring  the  great  palatine  arteries.  The 
flap  ijk  l,  attached  at  k  l,  is  turned  backwards  and  sutured  to  the 
nasal  septum  along  its  line  of  contact,  after  the  mucous  membrane 
on  both  flap  and  septum  has  been  removed  along  this  line.  The  two 
large  lateral  flaps  are  then  pivoted  inwards  and  their  anterior  extre- 
mities are  sutured  together  as  in  Fig.  329. 

Second  stage.— This  is    deferred    until    the  raw  surface  left  after 


Fig.  328. 


Fig.  329. 


Fig.  330. 


Fig.  331. 


158 


CLEFT   PALATE:    THE    LATE   OPERATION       159 

the  first  operation  has  completely  healed.  Flaps  A  B  c  D  and  a  1.  1  Q 
(Fig.  330),  composed  of  mucous  mcinl>rane  and  submucous  tissue  only, 
air  raised,  displaced  inwards,  and  sutured  to  each  other  along  their 
inner  margins.  A  row  of  sutures  is  also  placed  between  the  flap  on 
each  side  and  the  subjacent  edge  of  the  cleft,  indicated  by  the  dotted 
line  in  Fig.  331. 

Although  a  considerable  area  of  raw  surface  is  exposed  after  any 
of  the  foregoing  operations,  it  is  surprising  how  rapidly  it  becomes 
covered  by  mucous  membrane  and  how  slight  is  the  scarring.  Slough- 
ing of  the  flaps  seldom  occurs,  and  union  becomes  quite  firm  in  about 
five  days. 

The  late  operation  should  be  performed  at  about  the  third 
year.  In  several  instances,  where  the  cleft  has  been  narrow,  I  have 
obtained  good  results  in  cases  ranging  between  fifteen  months  and  two 
years  of  age,  but  in  the  majority  it  is  seldom  wise  to  attempt  the 
operation  before  the  child  is  at  least  two  and  a  half  years  old. 

Advantages : — 

1.  The  cleft  narrows  as  age  advances. 

2.  The  tissues  are  thicker  and  less  friable  than  in  the  young 

infant. 

3.  There  is  less  danger  of  postoperative  pneumonia. 

4.  The  co-operation  of  the  child  may  be  invoked  during  the 

healing  process,  so  that  it  refrains  from  crying  or  talking, 
and  from  pressing  its  tongue  against  the  palate. 

5.  If  the  operation  is  successful  the  appearance   of    the   palate 

and  the  mobility  of  the  soft  palate  are  unsurpassable. 
Disadvantages : — 

1.  Coincidently  with  the  appearance  of  the  teeth,  the  bacteria 

and  the  putrefactive  organisms  that  normally  inhabit  the 
mouth  increase  in  number  and  variety. 

2.  In  consequence,  the  danger  of  sloughing  is  very  great. 

3.  The  amount  of  tissue  available  for  union  depends  upon  the 

thickness  of  the  flap  alone. 

4.  If  there  is  the  least  tension  the  coaptation  sutures  commence 

to  tear  out  very  shortly  after  the  operation. 

5.  Owing  to  these  drawbacks  the  percentage  of  failures  is  greater 

than  the  percentage  of  successes. 
The  operation  (Langen beck's). — The  uvula  being  seized  with 
toothed  forceps,  both  edges  of  the  cleft  are  carefully  and  thoroughly 
pared.  Two  lateral  incisions  (Fig.  332)  are  then  made  midway  between 
the  alveolus  and  the  margins  of  the  cleft ;  they  should  commence  in 
front  of  its  anterior  limit,  and  extend  backwards  as  far  as  is  neces- 
sary to  relieve  tension  when  the  two  halves  of  the  soft  palate  are  ap- 
proximated.    The  mucous  membrane  of  the  hard  palate,  between  the 


i6o 


FACE,   LIPS,   AND   PALATE 


lateral  incision  and  the  edge  of  the  cleft  on  each  side,  is  then  thoroughly 
separated  with  a  curved  elevator.     One  blade  of  a  pair  of  rectangular 

scissors  is  now  introduced 
between  the  muco-perios- 
teum  and  the  bone,  and 
pushed  gently  backwards 
until  the  posterior  border 
of  the  hard  palate  is 
reached.  The  scissors  are 
then  rotated  until  the 
other  blade  lies  in  the 
naso-pharynx  above  the 
soft  palate,  which  is  di- 
vided at  its  attachment 
to  the  hard  palate  (Fig. 
333).  When  this  step  is 
completed,  should  the  two 
halves  of  the  soft  palate 
fail  to  meet,  the  lateral 
relieving  incisions  must 
be  extended  backwards. 
Sutures  of  silver  wire,  fine 
salmon-gut,  or  silk  are 
then  inserted  from  behind 
line  and  raw  lateral  surfaces  are  given  a 


Fig.  332. — Langenbeck's  operation  :  Flaps 
transfixed  by  silver  wires  held  in 
position  by  aluminium  plates. 


sutures     have     been    tied,    some 


MUCOUS  MtMBRAHE. 
OF  FLOOR  OF  H05E    •' 


forwards,    and  the  suture 
coating  of  Whitehead's  varnish. 

To  relieve  tension  after  the 
surgeons  pack  the  lateral  inci- 
sions with  gauze  in  order  to 
push  the  flaps  inwards;  but, 
owing  to  the  decomposition  of 
the  exudate  absorbed  by  the 
gauze,  this  is  not  a  satisfactory 
method.  C.  H.  Mayo  ties  the 
flaps  together  with  a  piece  of 
tape,  which  is  then  rotated  so 
that  the  knot  projects  into  the 
nasal  cavity.  Of  late  I  have 
transfixed  the  flaps  with  two  or 
four  strands  of  fine  silver  wire, 

and  fastened  the  ends  over  an  aluminium  plate  which  is  bent  over 
their  lateral  edges  (Fig.  332).  The  advantages  of  this  method,  apart 
from  the  relief  of  tension,  are  the  support  given  to  the  flaps  by  the 
wire  and  the  accurate  apposition  of  their  approximated  edges. 


333. — Langenbeck's  operation: 
The  soft  palate  and  the  muco- 
periosteum  of  the  hard  palate 
have  been  completely  separated 
from  the  bone. 


OPERATIONS   FOR  CLEFT   PAL  \  I  I  161 

After-treatment.  —The  mouth  should  be  rsprayed  daily  with  a 
mild  antiseptic  and  alkaline  lotion,  bul  no  attempl  should  be  made 
to  inspecl  the  wound  Leal  the  child  struggle  and  cry.  Liquid  nourish- 
ment in  small  quantities  a1  a  time  should  be  giyen  with  a  spoon  lor 
the  first  week,  after  which  the  amount  may  In-  increased.  A  baby 
must  lie  nursed  and  Boothed  to  prevent  it  from  crying,  and  an  older 
child  must  be  forbidden  to  talk.  The  stitches  should  not  be  removed 
until  the  tenth  day,  and  during  the  j.rocess  it  is  always  advisable 
to  make  the  child  drowsy  with  an  anaesthetic.  No  matter  how  perfect 
the  cosmetic  result,  no  operation  for  cleft  palate  can  be  called  successful 
unless  the  speech  he  improved.  Consequently  it  behoves  the  surgeon 
to  urge  the  necessity  of  lessons  in  elocution  by  a  competent  teacher 
as  soon  as  possible,  for  without  such  lessons  many  patients  will  he 
unintelligible  and  few  will  articulate  (dearly.  In  some  the  result  of 
careful  training  is  so  excellent  that  the  ordinary  observer  would  not 
suspect  the  presence  of  a  congenital  defect.  It  is  always  advisable 
to  see  the  patient  some  three  months  after  the  operation  ;  if  then  the 
soft  palate  appears  unduly  tense,  increased  flexibility  and  a  corre- 
sponding improvement  in  the  speech  will  be  obtained  by  teaching  the 
mother  or  the  nurse  to  massage  and  exert  pressure  upon  it  with  the 
ringer. 

BIBLIOGRAPHY 

Brophy,  Proceedings  Third  International  Dental  Congress,  Paris,  1900. 

Keith,  Arthur,  "On  Congenital  Malformations  of  the  Palate,  Face,  and  Neck," 

Brit.  Med.  Journ.,  1909,  ii.  312. 
Lane,  W.  Arbuthnot,  "The  Modern  Treatment  of  Cleft  Palate,*'  Lancet,  Jan.  4, 

1908. 
Owen,  Edmund,  Cleft  Palate  and  Hare-Lip.     London,  1904. 


THE  TONGUE 

By  W.   H.   CLAYTON-GREENE,   B.A.,   M.B., 
B.C.Cantab.,   F.R.C.S.Eng. 

Development.  —  The  tongue  is  developed  from  two  separate 
elements  in  the  floor  of  the  primitive  pharynx.  The  buccal  or 
anterior  portion  arises  during  the  third  week  (Keith)  from  the  1st 
branchial  bar  and  interbranchial  space,  by  the  development  of 
the  tuberculum  impar  (Fig.  334),  a  median  elevation.  It  was  at  one 
time  held,  as  the  name  suggests,  that  there  was  a  single  unpaired 


Fig.  334. — Diagram  showing  development  of  the  tongue. 

I,  Tuberculum  impar  ;  2,  posterior  portion  of  tongue,  developed  from  2nd  and  3rd  arches. 

element  entering  into  the  formation  of  this  part,  but  it  has  been 
shown  that  right  and  left  elevations  arise  and  fuse  to  form  the 
tubercle.  This  early  evidence  of  bilateral  origin  more  clearly  explains 
the  raie  conditions  of  bifid  tongue  and  median  cysts  sometimes  found. 

This  portion,  developed  from  the  mandibular  arch,  is  innervated 
by  the  special  nerve  of  this  part,  the  5th,  while  the  chorda  tympani, 
a  sensory  nerve  to  the  1st  branchial  cleft,  also  supplies  it. 

The  pharyngeal  portion  is  developed  from  the  fused  ends  of  the 
2nd  and  3rd  arches  (Fig.  334).  The  glossopharyngeal— the  nerve 
of  the  3rd  arch — supplies  this  part. 

162 


DKVKLOPMENT   OF    T1IK    TONGUE 


163 


Between  the  anterior  and  posterior^  portions  there  is  found  at  one 
period  a  well-marked  V-shaped  groove,  which  ultimately  is  occupied 

by  some  of  the  circn  in  vallate  papillae.  Farther  from  the  hypoplastic 
covering  in  the  middle  line  a  downgrowth  of  epithelium  takes  place 
which  forms  the  median  tubular  portion  of  the  thyroid  gland,  and 
which  normally  is  responsible  for  the  production  of  the  small  median 
depression  at  the  apex  of  the  V,  called  the  foramen  cascum  (Fig. 
334a).  Under  normal  conditions  this  duct  or  canal,  the  thyro-glossal 
duct,  should   disappear,  but  it  may  persist,  and   cysts  may  arise  in 


Fig.  334^. — A  more  advanced  stage  of  development  of  the  tongue 


1,  Foramen  cscum. 

any  part  of  its  course.  Such  cysts,  thyro-glossal  in  origin,  are  some- 
times met  with  in  the  substance  of  the  tongue. 

The  muscles  of  the  tongue  arise  in  a  curious  way  from  the  three 
posterior  head  segments.  They  grow  forward  into  the  fundament 
of  the  tongue,  carrying  with  them  their  appropriate  nerve,  the  12th 
cranial  or  hypoglossal. 

General  anatomy  of  the  tongue. — The  body  of  the  tongue 
is  composed  of  striated  muscle,  of  which  the  genio-hyo-glossus  and 
the  hyo-glossus  are  the  largest  extrinsic  muscles. 

The  dorsum  is  covered  with  a  peculiar  mucous  membrane,  and 
is  divisible  into  two  areas  which  correspond  closely  with  the  two 
portions  developed  respectively  from  the  tuberculum  impar — the 
lingual  portion ;  and  that  which  arises  from  the  2nd  and  3rd  arches, 
the  pharyngeal  part; — these  two  portions  being  separated  by  the 
V-shaped  groove  mentioned  above,  along  which  lie  the  circumval- 
late  papilla?. 


1 64  THE   TONGUE 

The  anterior  or  lingual  portion  is  covered  with  mucous  membrane 
beset  with  filiform  and  fungiform  papilla?,  the  former  being  delicate 
papillomatous  processes  of  connective  tissue  covered  with  epithelium. 
When  this  epithelium  proliferates  and  desquamates  in  excess,  and 
especially  when  bacteria  and  food  particles  collect  in  the  spaces 
between  the  papilla?,  the  condition  described  as  "  furred  tongue " 
arises.  In  the  middle  line  a  slight  fissure  may  be  seen,  which  in  some 
pathological  conditions  becomes  peculiarly  exaggerated. 

The  posterior  or  pharyngeal  portion  is  beset  with  small  nodular 
masses,  each  surrounding  a  central  pit,  visible  to  the  naked  eye. 
These  nodules  are  masses  of  lymphoid  tissue,  and  in  the  aggregate 
are  termed  the  lingual  tonsil. 

The  circumvallate  papilla?,  which  are  placed  at  the  junction  of  the 
two  parts,  are  actively  concerned  in  the  sense  of  taste ;  they  are 
curious  flat-topped  elevations  surrounded  by  a  trench  in  which  the 
taste-buds  are  embedded.  The  V-shaped  groove  along  which  these 
papilla?  He  is  termed  the  sulcus  terminalis,  and  at  its  apex  the  foramen 
ca?cum  may  be  occasionally  found.  At  its  extreme  posterior  part 
the  dorsum  lingua?  is  attached  by  a  median  fold  to  the  epiglottis, 
the  glosso-epiglottidean  fold,  while  laterally  it  is  connected  to  the 
pharynx  by  the  pharyngo-epiglottidean  folds,  which  together  with  the 
glosso-epiglottidean  folds  form  the  boundaries  of  the  two  lateral 
depressions,  the  vallecula?. 

The  inferior  surface  is  free  from  papilla?,  but  shows  a  median 
band,  the  fra?num  lingua?,  connecting  the  mucous  membrane  of  the 
tongue  with  that  of  the  floor  of  the  mouth ;  and  close  to  the 
latter,  on  either  side  of  the  fra?num,  the  openings  of  Wharton's 
duct,  the  duct  of  the  submaxillary  gland,  can  be  seen. 

On  either  side  of  the  fra?num  the  large  ranine  veins  are  clearly 
visible,  while  placed  still  farther  laterally  are  the  plica?  fimbriata? — 
folds  which  correspond  to  the  under-tongue  of  the  lemurs,  and  which 
mark  fairly  accurately  the  course  of  the  ranine  arteries. 

The  lateral  margins  possess  papilla?  similar  to  those  found  on  the 
anterior  part  of  the  dorsum,  while  just  in  front  of  the  anterior  palatine 
fold — a  band  which  descends  to  the  tongue  in  front  of  the  tonsil  and 
contains  the  fibres  of  the  palato-glossus — a  number  of  vertical  ridges 
are  situated,  the  folia  lingua?,  which  are  studded  with  taste-buds 
and  represent  the  papilla?  folia t a?  of  the  rabbit. 

The  muscular  mass  of  the  tongue  is  divisible  into  two  main 
groups,  the  extrinsic  muscles,  which  reach  the  tongue  from  surrounding 
bones  and  structures,  and  the  intrinsic  or  linguales,  which  are  confined 
to  its  substance.  Except  the  palato-glossus,  which  probably  derives 
its  nerve  supply  from  the  spinal  accessory  by  means  of  the  pharyn- 
geal plexus,  the  muscles  are  supplied  by  the  hypoglossal  nerve. 


i  i  i 


The  lymphatic  glands  draining  the  tongue. 

I,  Submaxillary  gland  and  its  lymph  nodes.     2,   Gland  on  hyo-glossus.     3,  Submental  group. 
4,   Deep  cervical  chain. 


Plate  86. 


ANATOMY   OF  THE   TONGUE 

Glands  of  the  tongue — There  are  a  number  01  small  racemose 

glands   situated    in    t  lie   posterior    part    of   t  lie    tongue,    and    a    feu    are 

found    in    relation    to    the   circuin  valla  te    papilla'. 

The  most   important,  bowever,  are  the  apical  glands  of   Blandin 

and  Nulm.  which  are  situated  on  the  inferior  surface,  a  little  d 
from  the  apex. 

They  are  mixed  serous  and  mucous  elands,  and  they  open  by  means 
of  three  or  four  small  ducts  on  either  side  of  the  upper  attachment 
of  1  he  fnenum. 

Arteries. — The  main  artery  of  the  tongue  is  the  lingual,  a  branch 
of  the  external  carotid,  which  reaches  the  organ  by  passing  under 
cover  of  the  hyo-glossus  muscle,  its  terminal  branches  being  the  sub- 
lingual, to  the  sublingual  gland,  and  the  ranine,  peculiar  to  the  tongue. 
There  is  no  free  anastomosis  between  the  vessels  of  the  two  sides. 
The  posterior  portion  is  supplied  by  the  dorsalis  lingua?  branch  of 
the  lingual,  reinforced  by  the  tonsillar  branch  of  the  facial. 

Veins — The  veins  do  not  follow  closely  the  course  of  the  arteries. 
There  are  two  venae  comites  which  run  with  the  lingual  artery  beneath 
the  hyo-glossus,  but  they  are  small,  the  greater  part  of  the  blood  being 
conveyed  back  by  the  ranine  veins,  two  large  vessels  situated  one  on 
either  side  of  the  fraenum,  immediately  beneath  the  mucous  membrane. 
These  veins  pass  backwards  over  the  hyo-glossus  and  usually  join 
with  the  vena?  comites  to  form  a  common  trunk  which  receives  the 
dorsalis  linguae  vein  before  joining  the  internal  jugular. 

Nerves. — The  anterior  two-thirds  of  the  mucous  membrane  is 
supplied  by  the  lingual  branch  of  the  inferior  maxillary  division  of 
the  5th  nerve,  accompanied  by  the  chorda  tympani,  which  may  convey 
special  taste-fibres  to  the  former,  but  more  probably  is  concerned 
with  supplying  the  lateral  margin  of  the  tongue.  The  posterior  third 
is  supplied  by  the  glossopharyngeal,  which  is  generally  considered 
the  special  nerve  of  taste.  A  few  fibres  are  also  derived  from  the 
superior  pharyngeal  branch  of  the  vagus.  The  nerve  supply  of  the 
muscles  has  been  described. 

Lymphatics  (Plate  86). — In  modern  surgery  the  course  of  the 
lymphatic  vessels,  influencing  as  it  does  the  spread  of  malignant 
disease,  is  of  the  utmost  importance. 

In  the  tongue  itself  there  are  two  main  sets  of  lymph-channels, 
the  rich  submucous  network,  and  the  scantier  intramuscular  vessels ; 
in  the  case  of  the  former,  it  is  to  be  noted  that  there  is  com- 
munication between  the  lymph-vessels  of  the  two  sides  across  the 
middle  line.  From  these  vessels  the  lymph  passes  to  the  glands, 
the  muscular  lymphatics  uniting  early  with  the  submucous  ;  and  it  is 
possible  to  define  four  distinct  sets  for  the  purposes  of  description, 
as  follows : — 


1 66  THE   TONGUE 

1.  The  apical  set  pass  from  the  submucous  network  on  to  the 
genio-hyo-glossus ;  some  of  the  vessels  pierce  the  genio-hyoid  and 
terminate  in  the  submental  glands  and  the  inferior  cervical  glands. 
This  latter  fact  is  of  supreme  importance,  since  in  malignant  disease 
of  the  tip  of  the  tongue  both  the  submental  and  submaxillary  regions 
may  escape,  the  infection  being  carried  directly  to  the  glands  which 
lie  along  the  internal  jugular  vein  at  the  point  where  it  is  crossed  by 
the  omo-hyoid  muscle. 

2.  The  lateral  set  descend  from  the  sides  of  the  tongue  and  ter- 
minate mainly  in  the  submaxillary  lymph-glands  ;  these  are  situated 
not  only  in  relation  to  the  submaxillary  salivary  gland,  but  are 
actually  embedded  in  its  substance — a  condition  which  necessitates 
removal  of  the  gland  in  malignant  disease.  A  few  lymphatic  channels 
pass  directly  to  the  superior  deep  cervical  glands.  The  lymph  from 
the  submaxillary  region  passes  into  these  cervical  glands,  one  of 
which,  situated  at  the  level  of  the  bifurcation  of  the  carotid,  is 
especially  important,  and  is  often  described  as  the  principal  gland 
of  the  tongue. 

3.  The  basal  set  arise  in  the  submucous  tissue  and  lymphoid 
follicles  of  the  posterior  part  and  pass  deeply  to  the  superior  deep 
cervical  glands. 

4.  The  median  set  arise  from  the  submucous  network  in  the 
middle  line  in  front  of  the  circumvallate  papilla?.  The  vessels  pass 
deeply  between  the  genio-hyo-glossi,  and  finally,  after  piercing  this 
muscle  and  the  hyo-glossus,  end  in  the  submaxillary  glands. 

A  point  of  special  importance  is  to  be  noted  in  connexion  with 
this  median  set,  namely,  that  according  to  Piersol  they  may  pass  to 
either  side  of  the  middle  line,  thus  accounting  for  infection  of  the 
glands  of  the  neck  on  the  side  opposite  to  that  upon  which  a  cancerous 
ulcer  is  found. 

The  lymphatics  from  the  floor  of  the  mouth  have  a  termination 
similar  to  the  termination  of  those  of  the  tongue. 

Occasional  glands  will  be  found  embedded  in  the  substance  of  the 
hyo-glossus. 

Methods  of  examination  of  the  tongue. — In  examining 
the  tongue  for  the  many  surgical  diseases  which  attack  it,  both 
inspection  and  palpation  are  necessary.  In  the  case  of  the  former  a 
good  light  is  essential,  and  the  patient  should  preferably  be  sitting 
opposite  to  the  surgeon.  If  daylight  should  not  be  available,  or 
if  swelling  of  the  tongue  should  impair  the  view,  a  laryngeal  mirror 
will  afford  great  assistance,  especially  in  cases  of  deep  haemor- 
rhage, or,  better  still,  a  small  portable  lamp  which  can  be  sterilized 
may  be  introduced  directly  into  the  mouth  ;  an  old  cystoscope  acts 
admirably. 


EXAMINATION  OF  Till     TONGUE 

A  metal  <>r  glass  tongue-depressor  should  be  at  hand,  and  lip- 
cetractois  are  required  in  a  difficult  case. 

If  the  tongue  be  foul  and  covered  with  fur  or  adherent  sloughs, 
-hould  be  gently  wiped  away  with  cotton-wool    swabs     • 

in  weak  carbolic  acid  (1-60),  or  the  surface  of  the  tongue  can  be 
dried  by  pressing  a  strip  of  white  blotting-paper  over  it — a  pro- 
ceeding which  brings  out  more  clearly  some  of  the  pathological 
conditions  met  with. 

Palpation  is  of  special  value  in  detecting  the  characteristic  indura- 
tion of  malignant  disease,  the  nodular  hardness  of  a  primary  chancre, 
and  the  local  tenderness  of  an  abscess ;  it  is  advisable  to  protect  the 
finger  with  a  glove  or  finger-stall. 

Histological  and  bacteriological  examination  supplement  the 
former  procedures.  These  methods  are  specially  required  in  the  case 
of  doubtful  ulcers,  of  which  a  piece — not  too  small — should  be 
removed  and  examined  microscopically.  If  too  small  a  piece  is  re- 
moved the  examination  will  be  very  unsatisfactory,  and  an  effort 
should  be  made  to  obtain  some  of  the  adjacent  apparently  healthy 
tissue,  since  this  will  show  in  a  more  convincing  manner  the  spread 
of  any  malignant  epithelial  cells. 

Bacteriological  investigation  is  required  in  some  of  the  parasitic 
diseases,  diphtheria  and  thrush,  and  abscess. 

Stress  must  be  laid  on  the  following  points  : — 

1.  It  is  not  easy  to  obtain  fluctuation  in  many  cases  of  abscess. 

2.  The  ulceration  which  occurs  around  a  calculus  impacted  in 
Wharton's  duct  is  easily  mistaken  for  malignant  ulceration. 

3.  Inflammatory  conditions  in  the  submaxillary  gland  may  be 
confused  with  acute  glossitis. 

4.  When  an  ulcer  is  acutely  tender  it  should  be  painted  with  some 
1  per  cent,  cocaine  solution  before  palpation  is  practised. 

MALFORMATIONS 

ABSENCE    OF   THE    TONGUE] 

Several  cases  of  so-called  absence  of  the  tongue  have  been  recorded, 
but  in  each  instance  the  case  seems  to  have  been  one  of  suppressed 
development  of  the  tuberculum  impar  rather  than  actual  absence  of 
the  organ.  In  such  cases  the  anterior  portion  of  the  organ  is  small 
and  rudimentary,  and  is  moreover  firmly  fixed  to  the  floor  of  the 
mouth,  rendering  free  movement  impossible.  The  base  is  always 
present  and  apparently  normal.  In  a  case  seen  by  me  the  above  con- 
dition was  associated  with  arrested  development  of  the  lower  jaw, 
the  whole  bone  being  small  and  underhung.  As  in  other  recorded 
cases  of  the  deformity,  the  speech  was  intelligible. 


T68  THE   TONGUK 

BIFID     TONGUE 

This  very  rare  condition  arises  from  the  incomplete  fusion  of  the 
two  parts  which  form  the  tuberculum  impar,  and  represents  a  develop- 
mental error  occurring  at  a  very  early  date,  the  form  being  comparable 
to  the  forked  tongue  of  the  reptilia.  The  malformation  may  be  asso- 
ciated with  hare-lip  or  cleft  palate. 

Treatment  is  comparatively  simple  in  those  cases  that  require 
it.  The  edges  of  the  cleft  are  pared,  and  the  raw  surfaces  united  with 
sutures. 

ANKYLOGLOSSIA 

Abnormal  fixation  of  the  tongue  occurs  as  either  a  congenital  or 
an  acquired  deformity.  The  congenital  variety,  when  not  associated 
with  a  rudimentary  condition  of  the  organ,  results  from  intra-uterine 
inflammatory  changes,  or  from  imperfect  destruction  of  embryonic 
structures  such  as  the  pharyngeal  membrane,  or  possibly  as  the  result 
of  imperfect  innervation  and  movement.  The  amount  of  control  of 
the  frsenum  upon  the  tongue  being  largely  influenced  by  movement  of 
the  organ,  as  shown  by  the  fact  that  some  cases  of  acquired  tongue- 
swallowing  are  due  to  stretching  of  this  anchoring  band,  it  is  possible 
that,  as  in  the  case  of  joints,  some  interference  with  the  normal  range 
of  movement  that  should  obtain  during  embryonic  life  is  responsible 
for  the  short  and  adherent  frsenum. 

Cases  such  as  the  one  described  by  Lapie,  where  there  were  large 
adhesions  between  the  tongue  and  the  palate — a  form  described  by 
French  writers  as  superior  ankyloglossia — suggest  either  some  inflam- 
matory source  for  the  adhesions,  or  the  persistence  of  some  membrane  ; 
while  in  the  more  common  variety — the  inferior  ankyloglossia,  which 
is  the  more  complete  when  the  tongue  is  very  rudimentary — it  would 
seem  probable  that  lack  of  motive  power  is  an  important  factor  in 
producing  this  result. 

In  this  inferior  form  we  can  recognize  two  varieties — the  complete, 
which  is  properly  considered  above  under  the  heading  of  congenital 
absence,  and  the  more  common  partial  form.  In  point  of  fact,  partial 
ankyloglossia  is  uncommon,  as  insisted  on  by  Butlin,  who  deprecates 
the  number  of  unnecessary  operations  often  performed  for  a  condition 
which  will  tend  to  rectify  itself.  The  routine  section  of  the  frsenum 
is  to  be  unhesitatingly  condemned.  Children  of  rather  weak  mental 
development,  who  learn  to  speak  late,  are  often  subjected  to  the 
operation  of  "  cutting  the  tongue-tie,"  in  the  hope  that  it  will  help 
the  development  of  speech.  This  idea  is  entirely  erroneous,  since, 
given  the  requisite  mental  power,  speech  is  quite  possible  in  the  most 
severe  forms  of  ankyloglossia. 

Should,  however,   a   case  present  itself  in  which  the  frsenum  is 


ANKYLOGLOSSIA 

obviously  too  short,  and  especially  if  the  child's  feeding  is  interfered 
with,  the  operation   becomes  necessary. 

Treatment.-  The  tongue  is  raised  with  the  index  and  middle 
fingers  of  the  left  hand,  the  Ersenal  band  is  rendered  tense,  and  is  nicked 
with  a  pair  <d  scissors  dose  to  the  jaw,  so  as  to  avoid  injuring  the 
ranine  vessels.  The  wound  must  not  lie  enlarged  by  tearing  up  tin- 
tongue  with  the  finger.  If  the  child  is  put  to  the  breast  or  given  a 
teat  to  Buck,  the  movement  of  the  tongue  thus  induced  will  help  to 
prevent  recurrence. 

This  operation  is  by  no  means  free  from  danger.  A  case  of  fatal 
lncmorrhage  is  quoted  by  Reboul,  while  macroglossia  developed  in 
cases  recorded  by  Burton,  Sedillot,  and  Dollinger.  If  the  tongue  is 
carelessly  stripped  up  after  the  band  has  been  divided,  an  ugly  wound 
is  left  which  may  form  a  troublesome  ulcer,  or  cause  so  much  cicatriza- 
tion that  the  tongue  becomes  more  fixed  than  it  was  at  first.  For 
serious  haemorrhage  following  division  of  the  frsenum  a  suture  should 
be  passed  through  the  tip  of  the  tongue,  a  strip  of  gauze  dusted  with 
iodoform  should  be  gently  packed  into  the  sublingual  region  on  to  the 
bleeding  area,  and  the  tongue  then  pulled  out  by  the  suture,  which 
in  turn  is  fixed  by  a  bandage  or  piece  of  strapping  to  the  chin ;  thus 
the  bleeding  area  is  fairly  firmly  compressed.  If  this  method  fails 
to  arrest  the  bleeding,  an  anaesthetic  must  be  given  and  an  attempt 
made  to  secure  the  bleeding-point ;  it  will  be  found  more  satisfactory 
to  under-run  the  vessel  with  a  curved  needle  threaded  with  catgut 
than  to  attempt  to  seize  it  with  forceps  in  the  friable  tissues  of  a 
young  child.     The  cautery  must  not  be  used. 

Acquired  Akkyloglossia 
This  condition  is  the  result  of  extensive  destruction  of  the  organ 
following  sloughing   in   smallpox,  or  mercurial  or  caustic  poisoning  ; 
occasionally  it  is  due  to  widespread  syphilitic  damage,  or  to  operative 
procedures  of  various  kinds. 

TONGUE-SWALLOWING 

Excessive  mobility  of  the  tongue  usually  results  from  extreme 
length  and  looseness  of  the  fraenum,  which  therefore  fails  to  control 
the  movements  of  the  organ  ;  the  tongue  itself  is  unduly  long.  Fair- 
bairn  records  a  case  of  suffocation,  and  Hennig  mentions  a  case  where 
the  child  died  in  a  paroxysm  of  whooping-cough,  apparently  from 
sucking  the  tongue  into  the  pharynx. 

A  similar  but  less  marked  condition  sometimes  occurs  in  patients 
under  the  influence  of  anaesthetics,  and  after  removal  of  portions  of 
the  tongue  it  is  one  of  the  complications  to  be  specially  treated. 

If  the  child  be  seen  in  a  state  of  suffocation  arising  from  this  cause, 


170  THE   TONGUE 

the  finger  should  be  introduced  into  the  mouth  and  the  tongue 
hooked  forward.  The  condition  is  likely  to  recur  ;  but  the  constant 
sucking  of  a  teat  will  help  to  prevent  it. 

INJURIES 
WOUNDS 

Injuries  to  the  tongue,  rarely  the  cause  of  serious  haemorrhage,  are 
usually  penetrating  wounds  produced  by  foreign  bodies  such  as  pipe- 
stems  and  fish-bones,  but  are  specially  important  in  that  an  abscess 
of  the  tongue  may  follow  and  the  foreign  body  may  be  retained  in  the 
tongue  substance.  Many  instances  are  recorded  where  pipe-stems  or 
teeth  have  been  removed  from  the  tongue  some  time  after  an  accident, 
comparatively  few  symptoms  having  arisen  during  the  interval. 

Occasionally,  severe  or  even  fatal  haemorrhage  may  occur,  as  in 
the  case  published  by  Bransby  Cooper,  where  the  pipe-stem  penetrated 
through  the  tongue  into  the  carotid  artery,  and  the  patient,  a  sailor, 
died  from  bleeding. 

The  tongue  may  be  severely  bitten  in  the  convulsions  of  epilepsy, 
eclampsia,  or  tetanus,  or  as  the  result  of  blows  or  falls  on  the  chin, 
and  the  bleeding  may  be  serious.  In  ordinary  circumstances  the 
tongue  is  rarely  severely  bitten  during  mastication,  but  if  the  5th 
nerve  is  paralysed  considerable  damage  may  be  done. 

Treatment. — The  chief  indications  in  treatment  are — first,  to 
control  any  haemorrhage  ;  and  second,  to  make  certain  that  no  foreign 
body  is  left  behind  in  the  muscular  substance. 

When  the  tongue  is  bitten  it  is  usually  the  anterior  part  that  suffers, 
a  part  easily  accessible  and  amenable  to  simple  treatment. 

On  the  other  hand,  in  punctured  wrounds  the  lesion  may  be  far 
back ;  and  if,  as  Butlin  points  out,  there  be  free  arterial  haemorrhage 
owing  to  the  fact  that  the  vessels  lie  deeply,  there  will  be  a  deep 
wound  in  which  a  foreign  body  may  be  hidden,  and  in  which  it  may 
be  very  difficult  indeed  to  secure  the  bleeding-point. 

For  the  temporary  arrest  of  severe  haemorrhage  the  manoeuvre 
recommended  by  Heath  should  be  adopted.  The  forefinger  is  passed 
to  the  back  of  the  tongue,  and  the  whole  organ  is  hooked  forward  with 
the  hyoid  bone,  the  lingual  arteries  being  thus  put  on  the  stretch. 

In  the  slighter  forms,  where  the  haemorrhage  is  mainly  venous, 
it  will  be  sufficient  to  approximate  the  edges  of  the  wound  with  catgut 
or  black  silk  ;  the  stitches  should  not  be  tied  too  tightly,  as  the  tissues 
swell  up  considerably,  but  they  must  arrest  the  bleeding. 

In  severe  haemorrhage  an  anaesthetic  must  be  given  ;  the  mouth 
should  be  widely  opened,  the  tongue  drawn  out  by  two  stitches  passed 
through  it  near  the  tip,  the  wound  enlarged  if  necessary,  and  a  search 


WOl'NDS   OF   THF  TONGUE 

made  for  the  bleeding-point.  This  La  a  difficult  matter  even  when 
skilled  assistance  is  at  hand,  and  without  it  the  operator  is  severely 
handicapped. 

It  may  be  wise,  owing  to  the  severity  of  the  haemorrhage,  to  per- 
form  laiyngotomy  and  to  plug  the  pharynx  before  attempting  to  deal 
with  the  bleeding.     I  strongly  recommend  this  in  a  « 1  i f  1  i * ■  1 1 1 1  i 
I  have  invariably  practised  it  before  any  extensive  operation  on  the 

mouth  Or  jaws,  and  am  Very  much  impressed  with  its  value. 

\  good  deal  of  difficulty  will  be  experienced,  even  under  the  best 

conditions,  in  applying  a  ligature  to  the  bleeding  vessel,  as  the  tongue 
tissue  is  friable  and  readily  tears  away  in  the  pressure-forceps.  If 
this  occurs,  it  is  better  at  once  to  under-run  the  vessel  with  a  silk 
ligature  by  means  of  a  curved  needle  ;  even  though  some  of  the  Ungual 
tissue  is  included  and  may  slough,  the  procedure  is  a  satisfactory  one. 
The  haemorrhage  having  been  arrested,  search  must  be  made  for  a 
foreign  body,  and  the  edges  of  the  wound  may  be  drawn  together, 
but  it  must  not  be  closed  completely. 

Cases  may  be  met  with  where  the  above  directions  will  fail,  necessi- 
tating ligature  of  the  lingual  artery,  or  even  of  the  external  carotid 
in  the  neck,  but  they  will  be  infinitely  rare. 

In  secondary  haemorrhage  the  same  treatment  should  be  carried 
out,  though  the  sloughing  condition  of  the  tissues  may  make  ligation 
of  the  vessel  a  matter  of  the  greatest  difficulty,  and  the  operator 
will  do  well  to  under-run  it  with  a  silk  ligature  at  once.  It  will 
rarely  be  necessary  to  tie  the  main  vessels  in  the  neck. 

The  after-treatment  of  wounds  of  the  tongue  consists  in 
promoting  oral  asepsis  with  mouth-washes,  of  which  carbolic  acid 
1-40,  hydrogen  peroxide  1-4,  are  the  most  effective.  Fluids  only 
must  be  taken,  and  if  there  is  much  swelling  and  pain  the  patient 
should  be  fed  per  rectum.  A  careful  watch  must  be  kept  for  oedema 
of  the  glottis,  a  complication  necessitating  tracheotomy,  also  for 
secondary  haemorrhage  and  for  abscess. 

Gunshot  wounds  are  to  be  treated  on  the  same  main  lines  as  punc- 
tured wounds  ;  they  are  very  liable  to  be  followed  by  secondary  haemor- 
rhage and  abscess,  and  therefore  should  not  be  closed  completely. 

Stings  of  the  tongue  are  to  be  regarded  as  poisoned  wounds. 
Generally  speaking,  the  treatment  should  be  similar  to  that  employed 
for  scalds,  but  there  is  some  danger  of  onset  of  oedema  of  the  glottis. 

BURNS    AND    SCALDS 

The  degree  of  severity  of  these  injuries  varies,  here  as  in  other 
parts  of  the  body,  from  slight  erosion  to  deep  destruction. 

Slight  burns  which  result  from  cigarettes  or  other  causes  merely 
lead  to  superficial  destruction  of  the  papilla?,   but  are   very  painful 


172  THE   TONGUE 

from  the  exposure  of  the  sensory  nerve  filaments.  Sometimes  a  slight 
burn  is  the  starting-point  of  an  ulcer,  and  in  some  cases  the  condition 
has  progressed  from  one  of  trivial  injury  to  epithelioma.  For  this 
reason  Butlin  warns  against  the  use  of  the  cautery  in  simple  diseases 
of  the  tongue. 

In  the  corrosions  produced  by  strong  mineral  acids  and  caustic 
alkalis  the  back  of  the  tongue  suffers  more  than  the  anterior  part  ; 
indeed,  it  is  not  uncommon  for  the  tongue  to  escape,  the  oesophagus 
and  stomach  receiving  the  chief  damage.  When  affected,  the  mucous 
covering  of  the  tongue  is  destroyed  and  peels  off  as  a  superficial  slough, 
and  the  whole  organ  swells  as  in  parenchymatous  glossitis.  Corrosive 
sublimate  produces  a  characteristic  white,  shrivelled  appearance. 

Severe  scalds  are  most  usually  met  with  in  children  who  have 
attempted  to  drink  out  of  a  boiling  kettle,  the  steam  rather  than  the 
water  producing  the  injury.  The  effects  are  often  very  severe,  the 
tongue  becoming  enormously  swollen  and  covered  with  blebs  ;  in  fact, 
a  state  of  acute  glossitis  is  set  up. 

In  all  the  above  conditions,  so  long  as  the  trouble  remains  limited  to 
the  tongue  there  is  little  need  for  anxiety,  but  unfortunately,  especially 
in  scalds,  owing  to  the  coexistent  damage  to  the  epiglottic  region  and 
the  upper  respiratory  tract,  oedema  glottidis  and  pneumonia  may  follow. 

General  treatment. — According  to  the  severity  of  the  burn 
or  scald,  solid  food  must  be  prohibited,  and  the  patient  should  be 
fed  on  fluids,  even  rectally  in  the  more  serious  injuries.  Ice  may  be 
sucked,  and  in  adults  the  painful  areas  may  be  painted  with  a  1  per 
cent,  solution  of  cocaine  ;  chlorate  of  potash  mouth-washes  are  of 
value  from  the  first ;  later,  when  the  pain  is  less,  astringent  lotions 
should  be  substituted. 

The  blebs  which  form  rarely  require  treatment. 

A  careful  watch  must  be  kept  for  signs  of  oedema  of  the  glottis, 
as  shown  by  stridor  and  dyspnoea.  In  adults  scarification  may  be 
of  value  occasionally,  but  in  children  it  is  wiser  to  perform  tracheotomy 
than  to  try  what  is  always  a  difficult  operation,  even  in  adults. 

INFLAMMATORY  DISEASES  -ACUTE 

Acute  inflammatory  lingual  diseases  are  here  dealt  with  according 
to  the  following  scheme  : — 

,    ~         ~  .  ,     i  Local.      f  Nervous. 

1.  Superficial.   (  Diffuse    { Membranous. 

2.  Deep. 

3.  Unilateral. 

4.  Inflammation  of  the  lingual  tonsil. 

5.  Abscess. 

6.  Gangrene. 


INFLAMMATORY   DISEASES  173 

1.  ACUTE   SUPERFICIAL   GLOSSITIS 

[a    seen     to     follow     inosl     burns   or    injuries  of  the   tongue   "I   slighl 
extent,  and  tends  in  these  cases  to  be  local  or  patchy,  readily  yielding 

to   mild    remedies  sueli   as  niout  li-waslies   01   emollient    applications  of 
borax,  Umax  and   hunev,  or  Listerine. 

The  diffuse  form  occurs  in  two  main  typos,  the  nervous  and  the 
membranous. 

The  nervous  variety,  which  is  often  unilateral,  is  associated  with 
trigeminal  neuralgia  or,  in  some  cases,  with  facial  paralysis.  There 
is  an  outbreak  of  vesicles  on  the  tongue,  which  becomes  red  and 
tender.  The  associated  nervous  affections  justify  us  in  regarding  the 
condition  as  related  to  herpes  zoster.  There  is  no  special  treatment ; 
sedative  mouth-washes,  tonics,  and  antipyrin  or  phenacetin  should 
be  tried. 

Membranous  glossitis  may  occur  as  part  of  a  generalized 
diphtheria,  the  disease  then  not  being  confined  to  the  tongue.  The 
tongue  and  the  submaxillary  lymphatic  glands  are  swollen.  Wharton 
published  a  case,  of  primary  diphtheria  of  the  tongue — a  very  rare 
condition. 

Pseudo-diphtheria. — True  diphtheria  can  only  be  diagnosed  if  the 
typical  Klebs-Loffler  bacillus  be  found,  other  forms  being  classed  under 
the  heading  of  pseudo-diphtheria.  Membranous  glossitis  is  occasion- 
ally met  with  in  children  who  are  suffering  from  measles  and  who 
are  the  subjects  of  impetigo  and  eczema.  The  membrane  contains 
desquamated  epithelium,  and  streptococci  or  staphylococci. 

Hutchinson  has  described  under  the  name  pellicular  glossitis  a 
more  chronic  form  which  occurs  in  smokers. 

Treatment  of  acute  superficial  glossitis  is  simple.  A  purge 
is  given  and  the  patient  is  put  upon  a  liberal  though  fluid  diet.  Ice 
may  be  sucked  if  there  is  much  pain,  and  10-15  grains  of  chlorate 
of  potash  should  be  administered  to  an  adult  until  a  drachm  has 
been  taken.  This  drug,  given  internally,  is  of  very  great  value  in  the 
inflammatory  or  ulcerated  conditions  of  the  tongue  and  mouth,  but 
must  be  given  with  caution,  especially  in  children,  as  it  is  liable  to 
produce  hsematuria.  Weak  solutions  of  cocaine  may  be  applied  occa- 
sionally for  pain,  or  a  mouth-wash  of  Listerine  used  as  an  alterna- 
tive. When  the  acute  stage  subsides,  astringent  lotions — alum,  10  gr. 
to  the  ounce,  or  zinc  sulphate,  2  gr.  to  the  ounce — should  be  sub- 
stituted. Occasionally  a  solution  of  bicarbonate  of  soda,  30  gr.  to 
the  drachm,  will  be  found  more  serviceable  than  the  other  lotions. 

In  the  membranous  forms  the  tongue  should  be  swabbed  with 
1-1,000  perchloride  of  mercury,  and,  if  the  Klebs-Loffler  bacillus  is 
isolated,  antitoxin  should  be  given. 


174  THE   TONGUE 

2.  DEEP   OR   PARENCHYMATOUS   GLOSSITIS 

This  is  a  comparatively  rare  condition  and  affects  adults,  males 
rather  than  females.  The  disease  comes  on  with  pain  and  stiffness  in 
the  tongue,  the  pain  often  being  referred  to  the  neck  and  ear ;  the 
tongue  swells  progressively  until  in  extreme  cases  it  cannot  be  retained 
in  the  mouth,  but  is  protruded,  indented  and  cut  by  the  teeth  which 
have  pressed  into  it.  The  swelling  is  hard  and  tender.  The  dorsum 
of  the  tongue  is  covered  with  a  thick  white  fur  and  there  is  profuse 
salivation,  the  glands  in  the  neck  are  swollen  and  tender,  and  the 
temperature  and  general  condition  are  indicative  of  an  acute  septic 
intoxication. 

Etiology. — This  affection  is  said  to  be  more  common  in  cold 
and  damp  weather.  Over-indulgence  in  alcohol  appears  to  have  a 
predisposing  influence,  but  the  most  important  factor  is  undoubtedly 
a  septic  state  of  the  mouth  and  teeth.  Of  the  many  organisms  which 
normally  inhabit  the  mouth,  the  staphylococci  and  the  streptococci 
seem  to  be  the  most  important  agents  in  exciting  the  condition. 

The  staphylococcal  form  is  the  less  acute  and  tends  to  be  more 
localized.  The  streptococcal  variety,  on  the  other  hand,  is  asso- 
ciated with  extreme  swelling  of  the  tongue,  which  may  pass  back 
to  the  aryteno-epiglottidean  folds,  and  of  the  glands  in  the  neck. 
Sabrazes  and  Bousquet  quote  a  fatal  case  secondary  to  puerperal 
fever,  and  Syme  records  two  cases  that  occurred  in  workmen  engaged 
in  cleaning  out  a  sewer.     Mercurial  glossitis  will  be  considered  later. 

Course. — The  disease  runs  on  to  resolution  in  the  milder  forms, 
but  some  permanent  thickening  and  stiffness  may  be  left  for  months 
after  the  acute  process  has  subsided.  In  other  cases,  suppuration 
follows,  a  deep  abscess  being  formed,  which  is  not  easily  detected. 
Occasionally,  sloughing  and  even  gangrene  may  occur,  and  the  tongue 
may  be  extensively  destroyed  and  become  fixed  to  the  floor  of  the 
mouth. 

The  risk  of  oedema  of  the  glottis  and  of  septic  pneumonia  is  very 
great  in  the  streptococcal  variety. 

After  the  acute  stage  has  subsided,  some  permanent  thickening 
of  the  tongue  substance  may  be  left — one  variety  of  the  "  glossites 
profondes  chroniques  "  of  the  French,  a  condition  easily  mistaken  for 
one  of  the  manifestations  of  syphilis. 

Treatment  must  be  active  from  the  start.  It  should  begin 
with  a  calomel  purge  ;  hot  mouth-washes  of  1-60  carbolic  acid  should 
be  prescribed,  and  leeches  applied  to  the  submaxillary  region.  If  the 
swelling  be  great,  as  in  the  streptococcal  type,  free  incisions  should 
be  made  into  the  dorsum  of  the  tongue  two-thirds  of  an  inch  on 
either  side  of  the  middle  line,  and  one-third  of  an  inch  deep  (Butlin). 


MERCURIAL  GLOSSITIS  175 

They  should  be  made  freely  with  a  cmved  bistoury.     The  relief  is 

almost    immediate,   and   seven*    Weeding    1-    rare. 

Modern  treatment  naturally  suggests  the  use  of  vaccines,  especially 
fan  the  streptococcal  infections. 

The  diet  iu  paronchvmatous  glossitis  should  he  the  same  as  in 
the  BupCrficial  form  (p.  173). 

Mi.rcurial  Glossitis 

This  affection  is  still  occasionally  seen,  though  much  more  rarely 
than  formerly.  It  is  distinguished  from  the  preceding  by  the  history, 
by  the  general  oedematous  state  of  the  tongue,  which  is  softer  than  in 
true  parenchymatous  glossitis,  and  by  the  accompanying  affection  of 
the  gums,  which  are  tender,  swollen,  and  vascular.  The  fetor  is  very 
great,  and  the  salivation  even  more  profuse.  There  is  considerable 
tendency  to  sloughing. 

Treatment  consists  in  stopping  all  mercury,  giving  2  drachms 
of  sulphate  of  magnesia  at  once,  and  10-15  gr.  of  chlorate  of  potash 
every  four  hours  up  to  a  drachm.  Leeches  may  be  applied  to  the 
submaxillary  region,  and  ice  should  be  sucked.  Incision  may  be,  but 
rarely  is,  required.  When  the  acute  symptoms  disappear,  salvarsan 
is  of  value,  and  tonics  are  demanded.  On  no  account  should  iodide 
of  potash  be  given. 

It  must  be  borne  in  mind  that  small  doses  of  mercury  may  produce 
this  condition  in  susceptible  subjects.  Cases  are  recorded  of  acute 
inflammation  of  the  tongue  having  followed  the  repeated  administra- 
tion of  blue  pill  or  calomel  for  purposes  other  than  the  treatment  of 
syphilis. 

3.  UNILATERAL   INFLAMMATION 

A  unilateral  condition,  hemiglossitis,  is  described  but  is  very  rare. 
It  is  never  very  acute,  and  should  be  treated  on  the  same  main  Unes 
as  the  above  ;    incisions  are  not  required. 

A  form  of  indurative  glossitis,  rather  chronic  in  nature,  is  some- 
times caused  by  the  impaction  of  a  salivary  calculus  in  Wharton's 
duct. 

4.  INFLAMMATION  OF  THE  LINGUAL  TONSIL 
This  condition  results  from  an  infection  of  the  lymphoid  follicles 
which,  collected  together  at  the  base  of  the  tongue,  form  the  mass 
described  as  the  lingual  tonsil.  In  some  cases  there  is  a  general  infection 
of  the  throat  and  base  of  the  tongue,  the  faucial  tonsils  being  the 
parts  chiefly  affected,  in  others  the  process  seems  confined  to  the 
lingual  base.  The  trouble  is  common  in  the  dry  days  of  summer, 
especially  in  towns,  and  is  probably  due  to  irritation  set  up  by  inhaled 


J7<>  THE  TONGUE 

bacteria  and  particles  of  horse-dung.     Anaemia  and  constant  use  of 
the  voice  seem  to  be  predisposing  causes. 

The  symptoms  are  practically  those  of  a  quinsy  ;  there  is  special 
pain  on  swallowing,  together  with  an  unpleasant  feeling  of  suffoca- 
tion, and,  from  the  situation  of  the  inflammatory  process,  there  is 
considerable  risk  of  laryngeal  obstruction.  On  examination  with  the 
laryngeal  mirror  the  base  of  the  tongue  is  seen  to  be  swollen  and 
congested. 

In  many  cases  the  acute  symptoms  subside,  leaving,  however,  a 
mass  of  swollen  lymphoid  tissue,  the  crypts  of  which  are  often  dis- 
tended with  inspissated  secretion  ;  in  others  an  abscess  forms,  which 
is  not  always  confined  to  a  follicle  (follicular  abscess),  but  may 
burrow  into  the  tongue  substance  and  form  a  purulent  collection 
of  considerable  size. 

Treatment. — In  the  milder  forms  a  mercurial  purge,  and 
mouth-washes  of  chlorate  of  potash,  followed  by  10-gr.  doses  of 
salicylate  of  quinine  every  four  hours,  will  effect  a  cure.  In  the  more 
severe  cases,  if  an  abscess  forms,  it  must  be  opened  carefully  with  a 
curved  knife,  the  patient  sitting  with  the  head  hanging  down  so  that 
the  risk  of  the  pus  finding  its  way  into  the  larynx  is  avoided. 

At  a  later  date,  if  concretions  form  in  the  epithelial  crypts,  they 
should  be  removed,  and  the  walls  of  the  crypt  and  follicle  destroyed 
by  the  cautery ;  or  if  there  is  general  hypertrophy  of  the  whole 
lymphoid  mass  it  may  be  removed  by  a  special  tonsillotome. 

5.  ABSCESS 

A  lingual  abscess  may  be  acute  or  chronic,  and  owe  its  origin  to 
a  number  of  different  causes.  It  may  follow  wounds  of  the  tongue, 
especially  those  in  which  a  foreign  body  becomes  included  in  the 
lingual  substance  ;  it  may  be  due  to  infection  from  carious  teeth, 
without  any  very  obvious  breach  in  the  integrity  of  the  mucous 
membrane  ;  or  it  may  result  from  the  acute  infections  previously 
described  under  the  head  of  Glossitis. 

Acute  abscess  is  characterized  by  a  gradual  onset,  accompanied  by 
pain  in  the  tongue  and  often  also  in  the  ear.  On  examination,  a  tender 
swelling  can  be  felt  in  the  substance  of  the  tongue,  but  fluctuation 
can  seldom  if  ever  be  detected. 

Chronic  abscess  is  much  rarer  than  the  acute,  and  is  due  to  organisms 
of  low  virulence  which  do  not  excite  a  violent  inflammatory  reaction  ; 
it  is  not  necessarily  tuberculous,  but  it  may  follow  the  secondary 
infection  of  a  tubercular  or  gummatous  area.  The  development  is 
very  slow  and  is  unaccompanied  by  any  marked  pain,  and  the  con- 
dition is  very  likely  to  be  mistaken  for  a  gumma. 

Treatment  consists  in  incision,  care  being  taken  that  the  pus 


INFLAMMATORY    DISEASES   OF   THE   TONGl   I      177 

has  free   exit  from   the   month.     Attention  should  be  given  to  any 

exciting  cause,  and  mouth-washes  should  be  employed. 

6.  GANGRENE   OF   THE   TONGUE 

Is  a  rare  complication.     It  lias  followed  an  acute  glossitis,  the  inflam- 
matory reaction  haying  been  so  severe  that  thrombosis  has  ensued. 
Syphilis  has  been  responsible  for  its  production  in  several  instant 
possibly  favoured  by  the  injudicious  administration  of  mercury. 

Cancrum  oris  may  spread  to  the  tongue,  and  lead  to  considerable 
destruction  of  the  tissues.  In  one  case  seen  by  me,  after  ligature 
of  both  lingual  arteries,  one  half  of  the  tongue  then  being  excised  for 
cancer,  the  remaining  half  became  gangrenous. 

Treatment. — The  general  treatment  consists  in  keeping  the 
mouth  as  clean  as  possible,  and  assisting  the  separation  of  the  dead 
material.  Frequent  washing  of  the  mouth  with  carbolic  or  perman- 
ganate lotions  should  be  enjoined,  while  occasional  applications  of 
chlorate  of  potash  or  iodoform  powder  are  of  great  service.  The 
former  is  somewhat  painful,  and  the  latter  must  be  very  sparingly 
used,  and  care  should  be  taken  that  the  patient  does  not  swallow 
the  drug. 

INFLAMMATORY    DISEASES-CHRONIC 

In  considering  the  following  affections  of  the  tongue  we  are  justified 
in  grouping  them  under  the  above  heading,  since  the  pathological 
findings  support  their  inflammatory  origin,  and  they  may,  therefore, 
fittingly  be  described  as  the  varying  expressions  and  results  of  a 
chronic  superficial  glossitis. 

In  the  following  descriptions  Butlin's  classification  is  adopted  : — 

1.  Erythema  migrans. 

2.  Dyspeptic  tongue. 

3.  Furrows  and  wrinkles. 

4.  Glossodynia  exfoliativa. 

5.  Herpes. 

6.  Leucoplakia. 

7.  Black  tongue. 

1.  ERYTHEMA   MIGRANS 

Synonyms.  —  Wandering  rash  ;  geographical  tongue  ;  superficial 
excoriation  (Miiller). 

Erythema  migrans  is  a  rare  affection  and  appears  to  be  almost 
entirely  confined  to  the  earlier  years  of  childhood,  occurring  in 
children  of  impaired  general  health  and  nutrition  who  are  nervous 
and  often  subject  to  skin  eruptions.    It  has  no  special  sex  predilection. 


17*  THE  TONGUE 

Small  circular  or  oval  patches  appear  on  the  dorsum  of  the  tongue, 
always  in  front  of  the  sulcus  terminalis.  At  first  the  size  of  a  pea, 
these  patches  gradually  enlarge,  forming  smooth  red  areas  from  which 
the  filiform  papilla  have  been  shed,  the  fungiform  occasionally  stand- 
ing out  the  more  prominently  in  consequence.  The  margin  of  these 
patches  is  distinctly  redder  than  the  centre,  is  sharply  defined  and 
limited  by  a  whitish  or  yellowish  border,  a  very  characteristic  fea- 
ture. The  patches  are  usually  multiple,  and  may  extend  from  the 
dorsum  of  the  tongue  on  to  its  under-surface,  the  result  being  that 
the  organ  has  the  appearance  of  being  cut  up  into  irregular  areas 
not  unlike  those  present  on  a  map — hence  the  term  "geographical 
tongue." 

The  affection  is  exceedingly  chronic,  and  does  not  respond  to 
treatment.  '  According  to  Parrot,  each  patch  or  ring  has  a  life-history 
of  seven  days,  spreading  to  the  periphery  and  gradually  disappearing, 
after  which  a  fresh  one  makes  its  appearance.  Nothing  definite 
is  known  of  its  etiology.  Parasites,  syphilitic  and  other,  have  been 
the  causes  accredited  by  many  writers,  but  there  is  no  evidence  to 
warrant  these  assumptions.  It  is  essentially  an  inflammatory  con- 
dition ;  according  to  Vanlair  and  Johnstone,  a  primary  affection  of 
the  derma,  "  a  subacute  papillitis,"  possibly  in  some  obscure  way 
under  the  influence  of  nervous  irritation  or  change.  Few  symptoms 
are  complained  of ;  indeed,  in  many  cases  the  condition  is  discovered 
during  the  routine  examination  of  the  child  ;  but  in  some  instances 
there  have  been  salivation  and  itching.  Vanlair  found  the  affected 
areas  were  hypersesthetic. 

Diagnosis. — Erythema  migrans  must  be  distinguished  from 
mucous  tubercles  by  the  greater  elevation  of  the  latter,  by  their 
general  grey  appearance,  and  by  the  presence  of  other  well-marked 
signs  of  syphilis  elsewhere. 

Treatment  has  no  marked  effect.  Attempts  should  be  made 
to  improve  the  general  health  of  the  child  with  tonics  and  cod-liver 
oil,  while  slightly  astringent  mouth-washes  of  alum  and  tannin  may  be 
ordered.  In  all  cases  the  teeth  should  be  carefully  examined,  and 
treated  if  necessary. 

2.  DYSPEPTIC    TONGUE 

Among  dyspeptic  subjects,  affections  of  the  tongue  are  extremely 
tommon,  as  is  natural,  since  to  some  extent  the  appearance  of  the 
congue  may  be  taken  as  a  reflection  of  the  condition  of  the  gastric 
and  intestinal  mucous  membranes.  A  great  variety  of  condi- 
tions have  been  described,  but  in  the  present  section  attention  is 
drawn  only  to  the  more  important  varieties,  ulcers  being  considered 
later. 


DYSPEPTIC   TONGUE  179 

The  dyspeptic  tongue  is  usually  enlarged,  its  surface  smooth,  more 
sensitive  and  redder  than  normal  ;  the  surface  epithelium  has  been 
shed,  and  the  sensitive  papillae  are  exposed. 

In  some  instances  the  pain  complained  of  is  of  a  severe  burning 
character;  in  appearance  the  tongue  seems  raw,  though  in  actual  fact 
the  "raw"'  areas  are  covered  by  a  thin  layer  of  epithelium.  Thesi 
arias  are  very  liable  to  suffer  from  slight  traumatism  which  would 
not  affect  the  normal  organ,  and  the  patient  has  recurring  attacks  of 
acute  soreness  and  excoriation. 

Pathologically  the  tongue  appears  to  be  the  seat  of  a  chronic  super- 
ficial inflammation,  though  here  the  response  is  peculiar  wrhen  com- 
pared with  the  other  varieties  of  this  affection,  in  that  its  sensitiveness 
is  increased  and  the  epithelium  has  no  tendency  to  proliferate. 

Gouty  subjects  are  especially  liable  to  this  condition. 

Treatment. — Suitable  measures  must  be  taken  to  deal  with  the 
dyspepsia,  or  gout  if  it  be  present,  and  the  teeth  must  be  carefully 
attended  to,  since  collections  of  tartar,  sharp  edges,  or  carious  stumps 
will,  if  allowed  to  remain,  render  any  treatment  abortive. 

Month-washes  of  chlorate  of  potash  or  other  non-irritating  anti- 
septics should  be  employed,  and  the  tongue  should  be  painted  occasion- 
ally with  chromic  acid,  10  gr.  to  the  ounce.  If  there  is  much  pain  a 
half-per-cent.  solution  of  cocaine  may  be  applied,  or  a  cocaine  ointment 
may  be  ordered.  Carbolic  acid  (1-80)  will  sometimes  succeed  when 
the  other  drugs  fail. 

3.  FURROWS 

The  tongue  is  sometimes  found  cut  up  by  a  number  of  deep  grooves 
or  furrows.  Some,  but  not  all  of  these,  are  the  result  of  chronic  inflam- 
matory changes,  either  simple  or  specific,  the  grooves  resulting  from 
the  scarring  in  the  submucosa  ;  the  syphilitic  varieties  will  be  con- 
sidered later.  In  other  cases,  as,  for  example,  the  "  fern-leaf  pattern  " 
tongue,  the  inflammatory  origin  is  not  so  clear,  and  we  are  forced  to 
the  conclusion  that  such  a  condition  is  only  one  of  the  natural  varieties 
of  configuration  in  which  the  depth  of  the  natural  grooves  or  sulci 
is  exaggerated.  The  natural  grooves  are  usually  longitudinal,  the 
acquired  transverse. 

When,  however,  fissures  or  cracks  result  from  chronic  inflam- 
mation, they  are  apt  to  be  a  source  of  anxiety  to  the  patient 
from  the  pain  they  cause,  and  to  the  surgeon  from  their  ten- 
dency, if  remaining  unhealed  for  a  long  time,  to  become  the  seat 
of  cancer. 

Treatment. — The  mouth  must  be  kept  clean  with  ordinary 
mouth-washes,  and  chromic  acid  applied  to  the  bottom  of  the  fissure 
by  means  of  a  small  camel's-hair  brush.     Ointments  are  very  useful. 


!8o  THE   TONGUE 

4.  GLOSSODYNIA   EXFOLIATIVA 

In  this  condition  violent  pain  is  complained  of  in  the  tongue 
out  of  all  proportion  to  the  local  change,  which  is  very  similar  to  that 
occurring  in  the  preceding  variety.  It  appears  to  be  a  neuralgia  of 
the  lingual  nerves  associated  with  a  thinning  of  the  epithelium  which 
may  be  compared  with  the  trophic  changes  occurring  in  some  forms  of 
trigeminal  neuralgia.    Anaemic  women  are  more  subject  to  it  than  men. 

Treatment. — The  application  of  nitrate  of  silver  or  the  actual 
cautery  is  sometimes  of  service.  Da  Costa  mentions  a  case  in  which 
the  chewing  of  a  piece  of  tarred  rope  relieved  the  pain. 

5.  HERPES 
Attacks  the  tongue  as  it  does  other  parts  of  the  body,  the  resulting 
eruptions  having  all  the  usual  features  of  the  herpetic  type.  There 
is  a  formation  in  the  epidermis  of  multiple  vesicles  which  are  sur- 
rounded by  inflammatory  zones.  In  some  cases  the  vesicular  forma- 
tion proceeds  to  such  an  extent  that  the  term  hydroa  has  been  given 
to  it.  The  ordinary  course  of  the  disease  is  for  the  vesicle  to  rupture, 
sometimes  becoming  pustular  first,  and  to  leave  an  ulcer  covered  with 
a  pellicle  which  consists  chiefly  of  desquamated  epithelium. 

Healing  usually  takes  place  under  appropriate  treatment,  but 
occasionally  the  ulcer  persists  or  even  spreads. 

The  amount  of  pain  attending  the  eruption  varies  enormously  ; 
in  some  cases  it  is  violent,  comparable  to  the  pain  in  herpes  zoster. 

The  disease  is  presumably  of  nervous  origin,  with  a  remarkable 
tendency  to  recurrence,  this  recurrence  being  favoured  in  susceptible 
subjects  by  excess  in  the  use  of  tobacco  or  alcohol,  or  by  exposure  to 
cold.  There  is  no  evidence  to  connect  the  disease  with  syphilis, 
although  it  is  often  associated  with  herpetic  eruptions  on  the  penis. 
Dyspeptic  subjects  are  said  to  suffer  from  it.  It  must  not  be  con- 
fused with  the  pustules  of  impetigo. 

Treatment. — A  sharp  mercurial  purge  should  be  given,  and 
careful  dieting  and  complete  abstinence  from  stimulants  must  be 
enjoined.  Arsenic  may  be  tried.  According  to  Butlin  there  are  two 
classes  of  case — one  in  which  a  mouth-wash  of  carbolic  acid,  spirits  of 
chloroform,  myrrh,  and  eau-de-Cologne  will  bring  about  speedy  reso- 
lution ;  another  in  which  an  ointment  with  a  basis  of  lanolin  and 
vaseline,  to  which  are  added  cocaine  and  a  weak  antiseptic  such  as 
boric  acid,  will  give  the  best  result. 

6.  LEUCOPLAKIA 
S  y  no  n  y  m  s.  —  Leucokeratosis  ;     ichthyosis  ;     psoriasis    lingua? ; 
smoker's  patch. 

We  now  come  to  the  most  common  form  of  chronic  supeificial 


LEUCOPLAKIA  181 

glossitis — a  form  which,  as  the  above  names  imply,  presents  itself  in 
i  number  of  difEeienl  guises, 

Pathology.-  As  the  result  of  some  irritation — and  it  by  no 
mesas  follows  that  the  irritant  is  of  the  same  intensity  and  nature  in 
every  case — a  chronic  inflammation  ensues  in  the  mucous  membrane 
of  the  tongue ;  the  papilla;  disappear,  a  corneous  change  takes 
plaoe  in  the  epidermis,  and  there  is  a  development  of  scar  tissue  in 
the  derma.  Changes  occur  chiefly  in  the  Malpighian  layer,  where 
the  cells  become  vacuolated  and  multiplied  and  loaded  with  eleidin 
granules. 

It  is  most  important  to  recognize  that  the  features  of  a  chronic 
inflammation  are  present  in  the  true  derma — a  phase  which  is  rightly 
regarded  as  indicating  a  want  of  stability,  a  precancerous  stage  in 
fact,  together  with  abnormal  and  misdirected  activity  on  the  part  of 
the  epithelial  cells  of  the  epidermis.  For  a  time  at  least  matters  are 
more  or  less  equally  balanced,  and  the  barrier  of  dermal  tissue  keeps 
the  epithelial  cells  in  check,  but,  weakened  by  the  effects  of  inflam- 
mation and  subjected  to  greater  strain  by  the  active  changes  in  the 
epithelium,  the  barrier  gives  way,  the  epithelial  cells,  sometimes  preceded 
by  a  round-celled  infiltration,  pass  beyond  their  normal  limits  into 
the  subjacent  derma,  and  a  nucleus  of  cancer  is  formed. 

Etiology. — Smoking,  syphilis,  and  gout  are  the  three  conditions 
mainly  accused  as  being  contributory,  if  not  actual  causative  agents, 
but,  while  they  may  be  all  or  severally  responsible  for  the  production 
of  chronic  superficial  glossitis,  it  is  now  generally  acknowledged  that 
the  disease  depends  upon  some  inherent  susceptibility  or  weakness  of 
the  superficial  tissues  of  the  tongue.  Just  as  some  patients  are  liable 
to  skin  eruptions  and  desquamations,  so  others  are  subject  to  super- 
ficial glossal  changes,  without  any  of  the  three  causes  mentioned  above 
contributing  to  them  in  the  least  degree. 

Although  syphilis  produces  a  chronic  inflammatory  change,  in  the 
superficial  layers  of  the  tongue,  and  in  this  respect  paves  the  way  for 
the  development  of  a  leucoplakial  state,  it  cannot  be  too  firmly  insisted 
on  that  leucoplakia  per  se  is  not  a  syphilitic  manifestation. 

Smoking,  especially  if  a  short  hot  pipe  is  used,  undoubtedly  pro- 
duces localized  areas  of  inflammation  which  are  known  as  smoker's 
patches,  and  which  are  classed  clinically  under  the  head  of  leuco- 
plakia. This  must  be  allowed  as  an  important  but  not  the  sole  cause 
of  the  condition.  Hartzell  has  reported  a  case  in  a  girl  of  only  11, 
but  it  is  very  rare  before  the  age  of  26-30. 

Almost  any  persistent  cause  of  lingual  irritation,  such  as  long- 
continued  drinking  of  crude  spirits,  or  the  presence  of  chronically 
infected  teeth  or  teeth-sockets,  may  act  as  potent  etiological  agents. 
Most  frequently  several  causes  are  at  work  simultaneously. 


iS2  THE   TONGUE 

Clinical  appearance. — The  appearance  of  the  organ  varies 
with  the  stage  of  the  disease  and  with  the  response  of  the  tissues. 
One  of  the  earliest  phases,  which  can  be  well  studied  in  a  smoker's 
patch,  is  the  development  of  a  smooth,  red,  slightly  raised  area  on 
the  dorsum  of  the  tongue.  In  cases  where  the  epithelium  has  not 
proliferated  to  any  extent,  or  where  it  has  been  shed,  this  stage  may 
persist  for  some  time,  and  involve  smaller  or  larger  areas  of  the  dorsum 
linguae ;  to  this  condition,  in  which  the  papillse  have  been  removed, 
the  term  "  red  glazed  tongue  "  has  been  applied.  In  others,  and 
perhaps  the  majority,  the  patch  slowly  becomes  covered  with  a  layer 
of  thickened  epithelium,  which  gives  it  the  appearance  of  having  been 
covered  with  white  paint  that  has  "  hardened,  dried,  and  cracked  " 
(Butlin). 

The  patches  may  be  multiple,  or  the  whole  surface  may  be  uniformly 
affected  ;  the  process  tends  to  spread  on  to  the  buccal  mucous  mem- 
brane, or  it  may  begin  there  and  spread  to  the  tongue.  The  thickened 
epithelium  may  form  a  definite  plate  of  a  warty  nature.  Cracks  and 
fissures  are  apt  to  appear,  and  a  spreading  ulceration  which  soon  becomes 
malignant  is  often  associated  with  it. 

Symptoms. — There  is  little  pain,  hence  many  patients  do  not 
ask  for  advice  until  an  advanced  stage  is  reached.  Occasionally, 
"  hardness  and  dryness  "  of  the  tongue  is  complained  of,  while,  if 
fissures  and  cracks  are  present,  highly  seasoned  food  or  hot  dishes 
may  cause  a  sharp  smarting,  or  even  severe  pain.     Taste  is  not  impaired. 

Course. — The  disease  is  extremely  chronic,  and  when  well 
advanced  a  cure  is  very  doubtful.  There  are  recurrent  attacks  of 
inflammation,  and  slowly  but  surely  in  a  large  number  of  cases  the 
inflammatory  stages  pass  into  malignant  ulceration. 

Drugs  have  little  effect  in  advanced  cases,  and  antisyphilitic 
remedies,  far  from  being  of  benefit,  are  often  actually  injurious.  When 
there  is  a  well-marked  history  of  syphilis,  or  if  other  stigmata  of  the 
disease  be  present,  mercury  and  iodide  may  be  tried,  but  they  should 
not  be  given  indiscriminately.  Very  marked  results  are  obtained  by 
the  use  of  salvarsan. 

The  prognosis  is  always  unfavourable. 

Treatment  is  mainly  directed  to  removing  any  source  of 
irritation,  such  as  carious  teeth  or  ill-fitting  tooth-plates.  Smoking 
must  be  prohibited.  Tobacco-chewing  is  especially  to  be  condemned. 
Spirits,  strong  wines,  highly  spiced  or  hot  foods,  should  not  be  taken. 

Mouth-washes  of  chlorate  of  potash,  and  paints  of  chromic  acid 
1-2  gr.  to  the  ounce,  salicylic  or  lactic  acid,  will  be  successful  only  in 
the  early  cases.  When  the  tongue  is  harsh  and  dry,  it  should  be 
wiped  dry  with  a  clean,  soft  cloth,  and  a  little  ointment  (see  p.  180) 
rubbed  in  night  and  morning.    No   caustics    should    be    employed ; 


LKUCOPLAKIA 


183 


there  is  no  doubt  that  tlirir  repeated  application  has  Led  to  increase 
of  the  inflammation  and  has  precipitated  the  development  <>f  cancer. 
Operation    (Fig.    335).  —  Any   local   thickened   plaque   or   wart 
should  be  excised   at  once,   since  it  is  probable   that   a    cancerous 


M  '  ^1 


Fig.   335. — Partial   removal  of  tongue  for   chronic  ulceration 
and  Assuring. 

An  incision  across  the  dorsum  and  the  under-surface  of  the  tongue  is  made  as  shown  in  a  and  /•, 
and    a    ventral    flap   turned  hack    as   in  c,   which  shews   the  end  of  the  stump.      This   flap  is 
brought  over  the  muscular  stump  and  sutured  to  the  cut  mucous  membrane  on  the  dorsum,  if. 
(After  Batlin  :  Burghard's  "  System  of  Operative  Surgery." 

change  has  already  begun.  Butlin  was  averse  to  interference  unless 
definite  warty  conditions  were  present,  but  Morestin  has  published 
some  cases  of  excision  of  large  leucoplakial  areas  with  a  fair 
amount  of   success.      He    excised    the    affected   areas   with   scissors, 


i84  THE  TONGUE 

and  united  the  edges  with  sutures.  In  any  case  a  very  careful 
watch  should  be  kept,  and,  if  there  is  the  slightest  suspicion  that 
cancer  has  supervened,  half  or  the  whole  of  the  organ  should  be 
excised. 

Radium  is  not  beneficial,  as  a  rule,  in  cases  of  leucoplakia.  There 
may  be  a  temporary  improvement,  but  the  disease  returns  worse  than 
before. 

7.  BLACK   OR   HAIRY   TONGUE    (NIGRITIES) 

Is  a  rare  condition  due  to  the  overgrowth  of  the  filiform  papillae.  The 
affected  area  is  usually  found  on  the  dorsum  just  in  front  of  the  cir- 
cumvallate  papilla?.  No  hairs  are  present,  but  the  long  hypertrophied 
papilla?  give  the  appearance  of  wet  hair.  The  colour  is  apparently 
due  to  bacterial  action,  or  to  stains  from  smoke  or  particles  of  food. 
The  disease  causes  no  symptoms  and  is  frequently  discovered  acci- 
dentally. A  mouth-wash  and  a  salicylic  paint  should  be  ordered. 
Mechanical  cleansing  by  gentle  scraping  with  a  curved  piece  of  whale- 
bone or  similar  instrument  is  often  useful. 


ULCERS 

Under  this  heading  we  consider  the  various  morbid  conditions 
which  lead  to  ulceration  of  the  tongue,  and  some  of  the  distinguishing 
features  which  characterize  the  individual  type.  Butlin's  valuable 
classification  of  the  different  varieties  has  been  followed,  but  it  would 
be  well  to  make  clear  at  the  outset  that  a  state  of  ulceration  is  merely 
a  further  stage  of  the  changes  considered  in  the  preceding  section. 

SIMPLE    ULCERS 

Ulcers  of  this  type  usually  result  from  long-standing,  neglected 
chronic  superficial  glossitis.  As  has  been  pointed  out  previously, 
there  is  a  gradual  transformation  of  the  vascular  submucosa  into 
scar  tissue,  with  the  inevitable  result  that  the  vitality  of  the  part  is 
impaired  owing  to  its  imperfect  nutrition.  The  relative  a  vascularity 
of  the  fibrosed  tissue  interferes  with  the  integrity  of  the  surface 
epithelium,  and  further  has  an  injurious  effect  upon  the  healing  of 
any  area  that  has  been  damaged  ;  and,  as  might  be  expected,  although 
in  many  cases  a  certain  amount  of  improvement  may  be  encouraged 
by  appropriate  treatment,  there  is  always  an  unfortunate  tendency  for 
the  recently  healed  ulcer  to  break  down  again  and  again. 

Such  ulcers  are  generally  situated  in  the  centre  of  the  tongue  and 
are  fissured  or  stellate  in  shape,  with  callous  edges.  Sometimes  by  a 
process  of  actual  sloughing  they  extend  laterally  and  deepen.  The 
amount  of  pain  they  produce  varies  greatly,  and,  no  doubt,  depends 


LINGUAL   ULCERS  185 

upon  the  depth  of  the  ulcer  and  also  the  state  of  the  Benaory  nerve 

filaments  of  the  papilla*.     Any  irritant   food  sets  up  a  binning  p. on 
which  lasts  for  some  time,  especially  if  the  lissure  is  a  deep  ani 
particles  of  food  become  lodged  in  its  depth. 

The  general  lines  of  treatment  arc  the  same  as  far  leucoplakia 
(see  above),  but  in  addition  the  floor  of  the  ulcer  mus1  be  carefully 
cleansed  and  local  treatment  in  the  shape  of  chromic  acid  paint. 
5-10  gr.  to  the  ounce,  undertaken  regularly  night  and  morning. 
This  application  is  certainly  one  of  the  best,  for,  in  addition  to  its 
marked  healing  properties,  it  allays  the  pain  and  irritability  of  the 
ulcer.  The  local  treatment  must  be  undertaken  with  great  patience 
and  discrimination  if  a  good  result  is  to  accrue,  and  it  is  safe  to  say 
that  no  two  cases  react  alike  to  the  applications. 

In  some  patients  a  weak  carbolic  lotion,  1-80,  will  succeed  when 
the  chromic  acid  fails ;  in  others  more  good  will  follow  the  use  of  a 
little  iodoform  powder,  tannic  acid,  or  chlorate  of  potash.  Dilute 
glycerine  of  tannic  acid  is  of  great  service  in  many  of  the  ulcerated 
conditions  of  the  tongue.  Nitrate  of  silver,  except  in  very  dilute 
solution  (1-500),  should  never  be  used. 

Again,  it  must  be  borne  in  mind  that,  even  when  these  ulcers  and 
fissures  occur  in  syphilitic  subjects,  the  mere  exhibition  of  mercury 
and  iodides  is  insufficient  to  effect  a  cure  ;  nay,  more,  by  their  powerful 
action  on  the  oral  mucous  membrane  they  may  make  things  worse — 
a  point  to  be  kept  carefully  in  mind  in  treating  syphilitic  ulcers  in 
the  mouth.  In  such  cases  the  local  treatment  should  be  as  advised 
above.  Chromic  acid  is  of  great  value  in  many  of  the  specific  lesions 
of  the  mouth. 

In  cases  wThere  the  ulcer  resists  all  treatment  or  relapses  frequently, 
especially  if  the  edges  become  indurated,  it  should  be  excised  by  means 
of  elliptical  incisions,  and  the  edges  of  the  wound  should  be  brought 
together  by  silk  sutures  after  ligation  with  catgut  of  any  vessels  that 
require  it.     The  stitches  should  be  removed  in  four  days. 

DYSPEPTIC   ULCEUS 

Arise  in  severe  or  exaggerated  forms  of  dyspeptic  glossitis  in  which 
the  surface  excoriations  break  down  into  true  ulcers.  They  are  usually 
situated  near  the  tip,  and  appear  as  small,  circular,  punched-out  mul- 
tiple ulcers,  with  a  red  areola,  associated  with  a  general  redness  or 
beefiness  of  the  anterior  part  of  the  tongue,  the  posterior  part  being 
covered  with  a  thick,  unhealthy  fur.  Some  patients  seem  possessed 
of  an  idiosyncrasy  in  regard  to  certain  articles  of  food,  which  have  a 
regular  tendency  to  produce  such  ulceration. 

The  general  treatment  is  the  same  as  for  dyspeptic  tongue, 
but  here  local  treatment  with  nitrate  of  silver  is  verv  beneficial. 


i86  THE   TONGUE 

HERPETIC   ULCERS 

While  herpetic  glossitis  is  chiefly  the  property  of  the  adult,  herpetic 
ulcers,  in  which  the  herpetic  vesicles  pustulate  and  ulcerate,  are 
more  commonly  met  with  in  unhealthy  children  between  the  ages  of 
6  months  and  3  years.  The  child  is  thin  and  often  ill  nourished,  the 
bowels  act  sluggishly,  the  mouth  is  hot  and  full  of  saliva,  and  the 
breath  offensive.  The  teeth  are  often  covered  with  tartar  or  are 
decayed.  The  ulcers,  which  are  multiple,  are  covered  with  the  mem- 
branous pellicle  described  above  ;  they  affect  the  anterior  portion  of 
the  tongue,  also  its  under-surface,  and  the  adjacent  buccal  mucous 
membrane. 

The  glands  in  the  submaxillary  region  may  be  swollen. 

Treatment. — Give  a  dose  of  salts,  castor  oil,  or  rhubarb,  and 
keep  the  bowels  acting  regularly.  Put  the  patient  on  a  plain  diet, 
including  fruit  but  avoiding  pastry.  Chlorate  of  potash  in  4-5  gr. 
doses  may  be  given  every  four  hours  for  two  days,  but  it  must  be 
used  with  care  as  it  often  has  an  irritant  action  on  the  kidneys.  The 
tongue  should  be  kept  clean  with  a  piece  of  soft  Turkey  sponge  soaked 
in  boric-acid  solution  or  a  solution  of  bicarbonate  of  soda  ;  later,  more 
stimulating  lotions  such  as  alum  or  chromic  acid  may  be  needed. 

Mercury  in  all  forms  must  be  avoided.  It  may  produce  a  gan- 
grenous stomatitis  in  these  subjects. 

TRAUMATIC   ULCERS 

"  Dental  ulcers  "  are  wounds  that  remain  unhealed  owing  to  per- 
sistent irritation.  They  result  from  rough,  broken,  or  irregular  teeth, 
which  are  often  carious,  or  from  ill-fitting  tooth-plates.  Sometimes 
a  broken  pipe-stem  may  be  responsible. 

They  vary  enormously  in  depth  and  appearance,  but  are  usually 
situated  on  the  sides  or  the  tip.  In  more  recent  cases  there  is  a  shallow 
erosion — sometimes,  however,  acutely  inflamed — surrounded  by  cede- 
matous  tissue,  and  associated  with  glandular  enlargement.  Such  a 
syndrome  points  to  an  acute  bacterial  infection  superadded  to  the 
trauma.  In  most  cases,  however,  the  ulcer  is  chronic,  perhaps  covered 
with  a  slough,  the  edges  becoming  progressively  indurated  the  longer 
the  ulcer  is  left  untreated. 

Patients  who  suffer  from  such  ulcers  are  usually  in  bad  health. 
The  tongue  is  covered  with  fur,  the  breath  is  foul,  and  there  is  often 
a  marked  condition  of  pyorrhoea  alveolaris. 

The  diagnosis  may  be  very  difficult  in  old  and  neglected  cases, 
and  the  observer  must  always  keep  in  mind  the  possibility  of  an  ulcer 
of  this  appearance  being  tuberculous,  syphilitic,  or  cancerous.  The 
general  points  which  influence  the  differential  diagnosis  will  be  con- 


LINGUAL    ULCERS 

rideied  under  the  appropriate  headings  to  avoid  repetition,  but  we 

must  here  draw  attention  to  the  tendency  of  such  ulcers,  if  nejji' 
to  become  ultimately  carcinomatous. 

In  making  a  differential  diagnosis  the  finding  of  some  local  cause 
is  exceedingly  important ;  only  recently  I  saw  a  patient  who  had 
a  chronic  nicer  which  had  been  diagnosed  as  malignant.  On  in- 
quiry it  was  found  that  the  patient  wore  an  ill-fitting  tooth-plate 
which  pressed  against  the  ulcer,  but,  as  it  was  not  always  worn,  its 
importance  in  producing  the  condition  had  been  overlooked  ;  when 
this  was  remedied  the  ulcer  speedily  healed  under  the  application  of 
chromic  acid. 

Treatment  consists  primarily  in  removing  the  source  of  irrita- 
tion, and  in  applying  local  remedies  such  as  chromic  acid,  and  ordering 
an  antiseptic  mouth-wash.  In  most  cases  the  response  to  treatment 
is  prompt.  There  is  one  point,  however,  which  requires  special  atten- 
tion. While  these  ulcers  are  truly  traumatic  in  their  incipient  stages, 
they  become  <:  infected  "  ulcers,  as  shown  by  their  liability  to  undergo 
acute  inflammatory  changes,  and  by  the  glandular  enlargement  which 
accompanies  them.  As  has  been  pointed  out,  a  condition  of  pyorrhoea 
is  often  associated  with  them,  which,  by  constantly  reinfecting  the 
ulcer,  renders  local  treatment  futile.  Such  cases  are  eminently 
suitable  for  vaccine  treatment,  which  in  pyorrhoea  has  succeeded 
admirably  in  the  hands  of  Goadby  ;  if  this  be  undertaken,  together 
with  the  remedies  advised  above,  healing  of  the  ulcer  will  be  speedy 
and  complete. 

In  cases  where  treatment  is  resisted  or  where  the  surgeon  suspects 
a  commencing  malignant  change,  a  piece  (or  better  still,  the  whole) 
of  the  ideer  should  be  excised  and  submitted  to  microscopic  exam- 
ination. If  a  malignant  change  has  supervened,  the  radical  operation 
for  lingual  carcinoma  should  be  performed. 

ULCER    OF    THE    FR.EXUM 

This  condition  occurs  in  children  affected  with  whooping-cough, 
and  is  due  to  the  tongue  being  forced  up  against  the  incisor  teeth 
in  the  violent  expiratory  efforts  of  the  coughing.  It  has  been  in- 
correctly stated  that  this  ulceration  is  the  cause  and  not  the  effect 
of  whooping-cough.  Sometimes  these  ulcers  are  associated  with  small 
papillomatous  growths  on  either  side  of  the  frsenum — Riga's  disease. 
The  ulceration  subsides  as  the  cough  disappears. 

MERCURIAL    ULCERS 

In  ulcers  resulting  from  the  injudicious  administration  of  mercury 
an  unclean  state  of  the  mouth  is  a  very  important  contributory  factor. 
Patients  whose  mouths  are  kept  scrupulously  clean  are  able  to  tolerate 


i88  THE   TONGUE 

mercury  better,  and  are  much  less  liable  to  stomatitis  and  ulceration, 
than  those  whose  mouths  are  septic  and  unhealthy. 

The  ulcers  are  multiple,  shallow,  and  irregular  in  outline,  surrounded 
by  a  red  area,  but  not  so  defined  as  the  dyspeptic  variety  ;  they  mav 
lead  to  extensive  sloughing.  The  tongue  as  a  whole  is  swollen,  showing 
indentations  from  the  teeth  at  its  sides,  the  breath  is  foul,  there  is 
profuse  salivation,  the  gums  are  swollen,  spongy,  and  retracted  from 
the  teeth,  which  are  loose  in  their  sockets.  Such  a  picture  is  seldom 
difficult  of  diagnosis. 

Treatment. — Give  a  saline  purge,  and  prescribe  chlorate  of 
potash,  10  gr.  every  four  hours  for  two  days  (see  above).  Order 
astringent  mouth-washes,  sulphate  of  iron,  or  acetic  alum  (E.  Lane). 
Nitrate  of  silver  is  of  value,  and  for  the  salivation  belladonna  may  be 
prescribed. 

Tuberculous,  syphilitic,  and  malignant  ulcers  will  be  considered 
specially  in  the  sections  on  Tuberculosis  (see  below),  Syphilitic- 
Diseases  (p.  191),  and  Malignant  Tumours  (p.  204). 

TUBERCULOSIS 

The  present  advanced  state  of  our  knowledge  of  the  manifesta- 
tions of  tuberculous  disease  attacking  the  tongue  is  largely  due 
to  Butlin's  writings,  and  his  descriptions  and  opinions  are  closely 
followed  in  the  ensuing  section.  In  the  past  many  of  these  cases 
were  mistaken  for  malignant  disease,  and  no  doubt  in  a  few  in- 
stances they  were  successfully  subjected  to  operative  treatment  and 
a  permanent  cure  of  cancer  was  claimed. 

The  systematic  examination  of  all  ulcers  and  tumours  removed 
has  shown  us  that  the  tongue,  like  other  tissues  of  the  body,  is  sub- 
ject to  tuberculous  invasion,  and  in  the  diagnosis  of  difficult  cases 
it  has  given  us  valuable  information,  and  occasionally  unpleasant 
surprises. 

Tuberculosis  attacks  the  tongue  either  as  a  primary  infection  of 
the  subepithelial  tissues,  the  bacilli  reaching  the  part  from  the  blood- 
stream or  by  means  of  infected  food  ;  or  as  a  secondary  complication 
of  tuberculous  disease  of  the  lung  or  alimentary  canal,  the  tongue  then 
being  infected  by  the  sputum.  When  we  think  of  the  rarity  of  tuber- 
culous disease  in  this  region,  as  compared  with  its  frequency  elsewhere, 
and  the  constant  exposure  of  the  lingual  surface  to  infected  sputum  in 
tuberculous  subjects,  we  are  forced  to  the  conclusion  that  the  tongue 
possesses  special  powers  of  resistance  ;  probably,  unless  there  is  some 
breach  in  the  surface  epithelium,  secondary  infection  of  the  organ 
does  not  occur. 

The  diagnosis  of  the  tuberculous  nature  of  a  lingual  ulcer  is  facili- 
tated by  the  discovery  of  signs  of  pulmonary  disease. 


LINGUAL   TUBKRCl'LOSIS  189 

All  authorities  do  not  accept  the  occurrence  of  primary  tuber- 
culosis, ami  it  has  been  held,  with  some  reason,  that  in  fche  reported 
cases  a  localized  patch  nf  pulmonary  tubercle  has  been  overlooked. 

Pathology. — The  microscopic    appearances  of    lingual  tubercle 

ire  peculiar.  It  is  rare  to  find  the  system  of  tubercles  at  all  well 
marked,  while,  even  the  giant  cells  are  scarce.  Again,  careful  staining 
will  often  fail  to  reveal  tubercle  bacilli. 

In  many  cases  the  arrangement  of  the  proliferating  endothelial 
cells  is  atypical,  and  in  the  form  which  is  described  as  "infiltrating 
tubercle"  they  may  be  mistaken  for  epithelial  cells,  and  a  diagnosis 
of  new  growth  (endothelioma)  may  be  made.  In  doubtful  cases  it 
may  be  necessary  to  inoculate  a  guinea-pig  with  the  suspected  material. 

The  various  tubercular  lesions  may  be  grouped  under  the  following 
headings  : — 

1.  Nodes. — Small  nodular  masses  varying  in  size  from  a  pin's  head 
to  a  nut,  multiple  in  cases  of  generalized  miliary  tubercle,  or  single 
in  the  locally  infected  cases.  These  nodules  consist  of  tuberculous 
granulations,  covered  at  first  with  normal  epithelium,  which  with  the 
increase  in  the  size  of  the  tubercle  is  liable  to  break  down  and  leave 
an  ulcerated  surface. 

The  centre  of  the  tuberculoma  may  undergo  caseation. 

2.  Fissures,  which  are  really  fissured  ulcers,  probably  originally 
simple  ones  that  have  become  infected  with  tubercle,  are  very  difficult 
to  diagnose.  When  the  edges  of  the  cleft  are  separated,  it  is  found 
to  be  much  deeper  than  was  expected,  and  to  be  lined  with  swollen 
granulations,  with  perhaps  caseating  margins.  The  material  scraped 
from  the  surface  may  be  shown  to  contain  tubercle  bacilli.  Occasion- 
ally the  margins  of  these  fissures  are  covered  with  protruding  growths 
of  a  papillary  nature,  to  which  the  name  tuberculous  papilloma  has 
been  applied. 

3.  Ulcers. — The  appearance  of  true  tuberculous  ulcers  is  very 
varied,  no  doubt  because  in  but  a  very  few  instances,  and  then  for 
a  short  time  only,  is  the  infection  "  unmixed."  Sooner  or  later  a 
tuberculous  ulcer  in  a  cavity  such  as  the  mouth  is  liable  to  contami- 
nation with  the  various  bacteria  and  mycelia  regularly  found  there, 
and  thus  becomes  modified  in  appearance.  This  fact  explains  win- 
some ulcers  are  covered  with  a  foul 'slough,  and  others  are.  surrounded 
by  an  indurated  zone  suggesting  cancer. 

It  is  a  feature  of  the  pure  tuberculous  process  here,  as  elsewhere, 
that  there  is  complete  absence  of  induration. 

4.  The  lupoid  ulcer,  which  has  been  described  by  Butlin  and  Leloir, 
is  exceedingly  rare,  and  is  caused  either  by  extension  of  the  lupoid 
ulceration  into  the  interior  of  the  mouth,  or  by  contagion  due  to 
the   drawing   of  the   tongue   over  the  infected   lips.     In   appearance 


i9<>  THE   TONGUE 

the  lupoid  ulcer  is  a  crusted  sore  without  surrounding  inflammation  ; 
when  the  crust  is  removed  a  nodular  or  mammillated  area  is  ex- 
posed, with  perhaps  some  small  caseous  foci,  the  general  colour  being 
bluish-pink. 

The  true  ulcer,  as  has  been  explained  above,  occurs  in  very  many 
different  forms.  The  pure  tuberculous  ulcer  is  oval  in  shape,  with  a 
pale,  flabby,  anaemic  surface,  the  granulations  having  a  glistening,, 
watery  appearance  ;  the  edges  are  sloping,  not  everted  or  indurated, 
and  rarely  undermined.  The  anterior  part  of  the  dorsum  is  the  usual 
situation  of  the  ulcer,  the  margins  being  often  involved.  Occasionally, 
caseous  areas  may  be  seen.  There  is  no  surrounding  inflammation. 
The  above  type  represents  the  unmixed  tuberculous  infection  ;  there 
are  also  dozens  of  different  varieties,  some  with  induration,  some 
with  surrounding  inflammation  and  oedema,  others  with  a  large  foul 
sloughing  surface,  but  no  useful  end  is  served  by  trying  to  classify 
these  diverse  appearances.  Suffice  it  to  say  that  in  a  doubtful  case 
a  careful  clinical  examination  of  the  lungs  and  a  microscopical  exam- 
ination of  the  ulcer  will  be  required  to  make  the  diagnosis  clear. 

The  adjacent  set  of  lymphatic  glands  which  drain  the  affected 
area  are  enlarged. 

Symptoms. — Tuberculous  manifestations  are  usually  painful 
when  ulceration  has  occurred  ;  indeed,  in  some  cases  there  is  excru- 
ciating pain,  and  the  misery  of  tuberculous  disease  in  this  situation 
may  be  compared  to  that  which  results  from  tuberculous  infection 
of  the  bladder.  There  is  a  tendency  to  profuse  salivation,  and  in 
neglected  cases  the  mouth  becomes  exceedingly  foul. 

Prognosis. — Most  authorities  agree  in  giving  a  very  gloomy 
prognosis.  Butlin  asserts  that  the  disease  is  usually  fatal  in  from  one 
to  two  years,  and  he  goes  on  to  say  that  "  the  patient  is  to  be  regarded 
as  fortunate  if  he  is  relieved  by  rapidly  progressive  tuberculosis  of 
the  internal  organs  before  the  ulcer  of  the  tongue  has  become  larger 
and  painful."     Pouzergues  and  Ducrot  take  a  more  hopeful  view. 

If  a  primary  lesion  can  be  removed,  or  if  an  early  secondary 
infection  can  be  radically  treated  and  the  pulmonary  disease  checked 
by  appropriate  remedies,  there  is  some  hope  of  the  picture  being 
a  little  brighter  in  future. 

Treatment. — The  main  line  of  treatment  is  operative.  All 
tuberculous  manifestations  should  be  freely  excised,  unless  pulmonary 
disease  or  other  constitutional  debility  is  a  contra-indication.  The 
question  of  the  wisdom  of  operating  in  the  presence  of  active  pulmonary 
tubercle  must  be  left  to  the  discretion  of  individual  surgeons  ;  but  if 
by  performing  a  comparatively  simple  operation  we  are  able  to  prevent 
the  pain  and  suffering  which  the  progress  of  the  ulcer  entails,  we  are 
entirely  justified  in  pursuing  that  course.     Even  in  the  presence  of 


SYPHILIS   OF   THE   TONGUK  ioi 

the  infected  sputum,  healing  docs  occur.     The  enlarged  glands  should 

also  be  removed. 

Cases  which  are  not  submitted  to  operation  should  be  treated  like 

those  of  chronic  glossitis  or  simple  ulcer  (q.v.).  Soothing,  weak 
astringent  mouth-washes  are  to  be  preferred,  and  caustics  are  to  be 
avoided. 

It  may  be  necessary  to  give  all  food  finely  minced  bo  that  its  pro- 
longed presence  in  the  mouth  for  mastication  may  not  be  needed. 

Cocaine  and  orthoform  are  useful  applications,  but  the  first  must, 
of  course,  be  used  with  care. 

An  application  to  the  ulcer  of  iodoform  1  gr.,  morphia  £-£  gr., 
borax  3  gr.,  by  means  of  a  soft  brush,  is  advisable  after  the  surface 
has  been  gently  cleaned  with  cotton-wool.  A  bismuth  ointment  is 
Sometimes  valuable  as  an  alternative. 

SYPHILITIC   DISEASES 

The  tongue  may  be  attacked  by  syphilis  in  any  of  the  three 
recognized  periods  of  the  disease,  and  the  frequency  with  which  the 
organ  suffers  makes  it  a  valuable  signpost  in  cases  of  doubtful  syphilis. 
As  in  other  parts  of  the  body,  these  syphilitic  manifestations  copy, 
often  in  a  very  accurate  manner,  the  appearances  produced  by  other 
pathological  conditions,  so  that  the  possibility  of  a  lesion  of  the  tongue 
being  syphilitic  must  always  receive  due  consideration.  At  the  same 
time  it  will  not  be  out  of  place  to  quote  Butlin's  warning  in  this  respect : 
"  Nothing  leads  to  greater  errors  in  diagnosis  and  treatment  than  the 
tendency  to  see  syphilis  in  every  form  of  obscure  affection  of  the  tongue, 
or  to  persist  in  a  diagnosis  of  syphilis  when  a  short  and  vigorous 
administration  of  antisyphilitic  remedies  has  proved  of  no  service." 

Chancre 

The  initial  lesion  of  syphilis  is  occasionally  found  on  the  tongue. 
Fournier  discovered  it  here  53  times  in  642  cases  of  extragenital 
chancre.  The  irfection  is  conveyed  by  direct  personal  contact,  or 
indirectly  by  the  use  of  cups,  pipes,  glass-blowing  and  other  instru- 
ments, contaminated  by  infected  persons.  As  a  rule  the  chancre  is 
situated  on  the  anterior  part  of  the  tongue,  and,  as  in  the  case  of  the 
genital  affection,  may  or  may  not  show  well-marked  ulceration. 

The  pathology  of  the  lesion  is  the  same  here  as  elsewhere  ; 
there  is  extensive  proliferation  of  the  fixed  connective-tissue  cells  of 
the  subepithelial  layer,  some  infiltration  of  leucocytes,  and  thickening 
of  the  arteries  and  veins.  As  these  changes  cease  fairly  abruptly  at 
the  margin,  the  chancre  feels  like  a  hard  nodular  mass  embedded  in 
the  normal  supple  tongue.  The  amount  of  ulceration  present  probably 
depends  upon  the  extent  to  which  the  epithelium  is  affected,  upon 


192  THE   TONGUE 

the  degree  of  "  mixed  "  infection  that  has  occurred,  and  upon  the 
presence  or  absence  of  trauma. 

The  smooth  chancre  appears  as  a  firm,  hard,  well-defined  nodule, 
aptly  compared  in  shape  and  feel  to  a  nux  vomica  seed  embedded 
in  the  tongue.  The  ulcerated  form  has  a  characteristic  appearance 
like  the  bowl  of  a  spoon,  the  induration  being  accompanied  by  more 
infiltration  than  in  the  preceding  variety,  and  by  pain  and  salivation. 
A  fissured  chancre  has  been  described. 

Within  ten  days  of  the  appearance  of  the  primary  lesion  the  sub- 
maxillary and  submental  lymphatic  glands  will  be  found  enlarged  ; 
and,  as  so  often  happens  in  the  glandular  enlargement  associated  with 
an  extragenital  chancre,  the  degree  of  swelling  is  considerable,  and 
relatively  greater  than  that  of  inguinal  adenitis  in  genital  chancres. 

The  characteristic  induration,  the  glandular  enlargement,  and  the 
short  history  of  the  lesion  make  the  diagnosis  easy  ;  in  a  doubtful 
case  it  may  be  necessary  to  try  Wassermann's  reaction,  or  even  to 
wait  for  symptoms  of  the  generalized  disease,  before  a  definite  opinion 
can  be  given. 

Active  treatment  of  the  disease  must  be  undertaken  as  soon 
as  the  diagnosis  has  been  made  ;  a  mercurial  mouth-wash  should  be 
ordered,  and  a  little  iodoform  powder  may  be  applied  occasionally  to 
the  ulcerated  varieties. 

The  infectious  character  of  the  disease  in  this  and  in  the  secondary 
stages  should  be  pointed  out  to  the  patient. 

I  may  add  that  soft  chancre  of  the  tongue  has  been  described  by 
Emery,  Sabouraud,  and  Fournier. 

Secondary  Stage 

In  this  stage,  mucous  nodules  or  patches  are  met  with  which 
present  the  characteristic  pathological  features  of  syphilitic  lesions, 
arising  from  localized  proliferation  of  the  connective-tissue  cells,  the 
resulting  elevation  being  covered  with  thickened  epithelium. 

The  proliferation  of  the  connective-tissue  cells  extends  over  a 
wider  area  than  in  the  primary  lesion,  and  does  not  proceed  to  the 
same  degree  of  development,  the  resulting  papule  or  projection  only 
just  standing  out  from  the  surface  of  the  tongue. 

Influenced,  no  doubt,  by  the  agencies  referred  to  above,  the 
surface  of  the  patch  may  ulcerate,  even  deeply,  and  the  so-called 
secondary  ulcer  may  be  formed.  These  patches  may  be  met  with 
anywhere  on  the  tongue  or  fauces,  but  they  are  more  common  on 
the  dorsum  in  front  of  the  circumvallate  papillae  ;  they  are  also  found 
on  the  under-surface. 

In  their  course  they  arise  as  small  nodular  elevations  the  size  of 
a  pea,  and  gradually  extend  to  the  size  and  shape  of  an  almond.     The 


SYPHILIS   OF   THE   TONG1   I 

Burfaoe  epithelium,  being  thickened,  takes  on  a  greyish-white  appear- 
ance :  tin*  edge  is  sharply  defined  and,  unless  ulceration  has  occi 
there  Is  no  surrounding  redness.  If  the  epithelium  is  shed,  a  smooth, 
red,  elevated  Burface  is  left  behind;  l>ut  in  their  usual  position  on 
the  dorsum  the  patches  are  exceedingly  Liable  to  become  fissured  or 
ulcerated,  and  accordingly  modified  in  appearance. 

The  diagnosis  bas  to  be  made  from  Leucoma,  bul  the  mucous 
patches  are  no1  bo  pearly-white  as  those  of  Leucoma,  while  ulceration, 
if  present,  extends  more  deeply  in  the  syphilitic  Lesions.  Other 
symptoms,  too,  of  generalized  syphilis  will  be  present. 

Constitutional  treatment  of  the  disease  is  required,  but  for 
local  application  Butlin  found  that  chromic  acid,  10  gr.  to  the  ounce, 
has  a  wonderful  action,  far  superior  to  that  of  any  mercurial  remedies 
applied  locally. 

In  this  as  in  all  forms  of  syphilitic  or  other  ulceration  the  lines 
of  treatment  laid  down  for  superficial  glossitis  should  be  carried  out 
rigidly. 

Tanturri  has  described  an  affection  of  the  lymphoid  follicles  at  the 
base  of  the  tongue,  a  syphilitic  hypertrophy  of  the  adenoid  tissue. 

Tertiary  Stage 

In  the  third  stage  the  tongue  is  more  deeply  affected.  The  patho- 
logical changes  again  concern  ,the  fixed  connective-tissue  cells,  which 
are  stimulated  to  proliferate,  either  locally  or  generally. 

In  the  local  form  the  aggregation  of  mononuclear  cells  leads  to 
the  development  of  a  nodular  mass,  and  the  tendency  of  these  newly 
formed  cells  to  necrose  from  imperfect  nutrition  causes  the  formation 
of  the  central  slough  or  dead  core  of  the  gumma.  When  the  process 
is  more  widely  diffused  this  tendency  to  local  degeneration  is  not 
marked,  but  special  complications  attend  and  follow  this  connective- 
tissue  overgrowth. 

Fournier  describes  two  main  varieties,  superficial  sclerosing  glossitis 
and  deep  or  parenchymatous  glossitis  :  in  both  the  essential  pathological 
change  is  the  same  ;  it  is  only  the  extension  of  the  process  into  the 
deeper  parts  of  the  tongue  in  the  latter  form  which  causes  any 
difference. 

In  the  superficial  form  the  main  change  is  in  the  connective 
tissue  subjacent  to  the  epithelium,  and  leads  to  the  development  of  flat 
plate-like  masses  beneath  the  epithelium.  The  latter  is  soon  affected  ; 
proliferating  abnormally  at  first  under  the  stimulus  of  the  infection, 
its  nutrition  becomes  impaired  as  the  inevitable  contraction  of  the 
newly  formed  connective  tissue  supervenes,  and  there  is  a  ready 
tendency  to  ulceration.  Further,  in  its  contraction  the  fibrous  tissue 
causes  disfigurement  of  the  tongue  surface,  and  the  formation  of  the 


i94  THE   TONGUE 

clefts  and  fissures  seen  on  the  surface  of  the  syphilitic  tongue.  Some- 
times the  arrangement  is  quite  regular,  the  indurated  surface  of  the 
tongue  being  cut  up  by  lines  which  divide  it  into  perfect  quadrilateral 
areas  ;    in  others  the  arrangement  is  very  irregular. 

In  the  parenchymatous  form  the  cellular  hyperplasia  affects  the 
deeper  parts  of  the  organ,  and  gives  rise,  in  fact,  to  a  general  cirrhosis. 
In  the  early  stages,  when  the  connective-tissue  cells  are  actively 
proliferating,  the  tongue  is  swollen,  often  extremely  so,  indented 
laterally  by  the  teeth,  and  may  be  eroded  and  ulcerated.  In  the 
extreme  cases,  which  are  rare,  however,  a  condition  of  syphilitic 
macroglossia  is  set  up. 

Sooner  or  later  the  period  of  active  cell-formation  is  replaced  by 
the  period  of  fibrous  contraction  or  sclerosis  ;  the  tongue  becomes 
shrunken  and  distorted  as  in  the  superficial  variety,  but  to  a  much 
greater  extent.  As  in  the  case  of  the  cirrhotic  liver,  the  surface  is 
mammillated  and  lobulated,  the  lobules  being  separated  from  one 
another  by  deep  fissures  ;  there  is  deep  induration,  not  unlike  that  of 
cancer,  but  more  generalized.  Ulcers,  often  intractable,  sometimes 
malignant,  are  apt  to  form  in  the  depths  of  these  fissures. 

Gummata  may  develop  either  superficially  or  deeply.  The  super- 
ficial variety,  often  multiple,  is  characterized  by  its  appearance  on 
parts  of  the  tongue  which  are  not  irritated,  and  by  its  breaking  down 
and  forming  a  gummatous  ulcer  early.  The  deep  gummata  arise  fre- 
quently in  the  centre  of  the  tongue,  in  the  "  avascular  area,"  though 
they  may  be  found  at  the  sides. 

Men  are  much  more  liable  to  this  manifestation  of  syphilis  than 
women.  The  gummata  develop  as  round  or  oval  deep-seated  tumours, 
which  may  cause  great  difficulty  in  diagnosis,  simulating  as  they  do 
new  growths  or  abscesses.  When  they  break  down,  which  they  are 
somewhat  slow  to  do,  they  may  lead  to  great  destruction  of  the  tongue 
substance,  and  appear  as  indolent,  painless,  gummatous  ulcers. 

The  gummatous  ulcer  is  characterized  by  its  ragged  borders,  some- 
what undermined  edges,  and  sloughy  surface  ;  if  of  long  standing 
it  may  show  induration  ;  the  glands  are  not  enlarged  unless  some 
other  infection  is  superadded.  The  painlessness  and  slow  development 
of  the  ulcer  are  two  points  of  most  importance  in  the  diagnosis,  but 
in  many  doubtful  cases  iodide  and  mercury  must  be  administered 
before  a  suspicion  can  be  converted  into  a  certainty. 

Tertiary  affections  of  the  tongue,  as  Butlin  points  out,  are  prone 
to  attack  the  dorsum. 

The  general  treatment  of  tertiary  syphilis  must  be  undertaken, 
and  locally  the  ulcers  are  to  be  cleansed  with  washes  and  painted 
with  chromic  acid,  10  gr.  to  the  ounce.  In  some  obstinate .  cases, 
iodipin,  given  either  hypodermically  or  by  the  mouth,  is  of  very  great 


DERMOID   CYSTS   OF   T1IK   TONGUK 


servioe ;  and  it  may  be  stated  generally  thai  the  oral  and  lingual 
manifestations  of  syphilis  are  rapidly  benefited  by  a  course  of 
salvarsan. 

CYSTS  AND  TUMOURS 

DERMOID    CYSTS 

The  group  of  cystic  tumours  in  the  tongue  to  which  the  term 
dermoid  may  be  applied  consists  of  three  main  varieties,  depending 
upon  the  particular  developmental  irregularity  responsible  for  their 
formation. 

In  this  consideration  we  must  take  into  account  the  changes  which 
occur  in  the  developing  neck.  In  the  middle  line  of  the  neck,  where 
the  lateral  folds  meet  one  another  in  the  process  of  fusion,  portions 
of  the  epidermis  may  become  unnaturally  included  in  the  underlying 
mesoblast,   and    may  later  develop  into  the  type  of  cyst  called  by 

3    2 


Fig.  336. — Branchial  arches  and  cleft. 

i.  E  xternal  cleft  depression  ;  2,  internal  cleft  depression  ;  3,  cleft  membrane. 

Bland-Sutton  sequestration  dermoid ;  such  dermoids  may  be  met  with 
embedded  in  the  substance  of  the  tongue. 

Again,  if  the  process  of  obliteration  of  the  branchial  depressions 
by  the  opercular  folds  of  the  cervical  sinus  be  imperfectly  carried  out, 
embryonic  remains  may  later  develop  into  cystic  tumours.  Between 
each  branchial  bar  and  the  next  there  is  a  depression  or  cleft  recess, 
limited  by  the  cleft  membrane — the  outer  part,  or  external  cleft 
depression,  being  lined  by  epiblast ;  the  inner,  or  internal  cleft  depres- 
sion, by  hypoblast  (Fig.  336).  Dermoid  cysts  arising  in  connexion 
with  the  external  cleft  depression  present  all  the  usual  characteristics 
of  a  dermoid  cyst,  being  filled  with  pultaceous  sebaceous  matter  and 
having  typically  epidermal  walls,  upon  which  hairs  may  be  found. 
Cysts  arising  from  the  inner  cleft  depression,  markedly  rare,  appear 
rather  in  the  form  of  pharyngeal  diverticula,  or  more  rarely  as  cystic 


196 


THE   TONGUE 


tumours  containing  glairy  fluid,  and  in   most  cases  some  connexion 

with  the  pharyngeal  wall  can  be  discovered. 

Strictly  speaking,  such  dermoids  as  these  do  not  occur  primarily 

in  the  tongue,  being  generally  found  in  the  submaxillary  region,  from 

which,  by  extension,  they  may  invade  the  lingual  substance. 

The  third  variety  is  the  one  which  develops  in  connexion  with  the 

median    thyroid   rudiment    (Fig.    337)  ;    such    cysts   or,   it    may    be, 

solid  tumours  occur 
deeply  in  the  pos- 
terior part  of  the 
tongue  ;  this  form 
is  called  by  Bland - 
Sutton  a  "  tubirfo- 
dermoid." 


Sequestration 
Dermoids 

These  cysts 
usually  occur  in 
the  anterior  part  of 
the  tongue,  in  the 
middle  line,  and 
are  then  situated 
between  the  two 
genio  -  hyo  -  glossi ; 
sometimes  they  are 
laterally  placed, 
but  this  is  owing 
to  their  irregular 
extension,  or  more 
probably  to  the 
cysts  having  arisen 
in  a  branchial  re- 
cess. Such  cysts 
grow  slowly  and 
protrude  either 
into  the  mouth  or  into  the  submental  region  ;  in  advanced  cases  a  very 
large  swelling  may  be  formed  which  renders  closure  of  the  mouth 
impossible.  The  swelling  has  a  curious  doughy  feel,  pits  on  pressure, 
and  in  some  cases  is  of  a  yellowish  colour. 

If  the  cyst  has  been  allowed  to  rupture,  or  has  been  incompletely 
removed,  dermoid  fistulce  form,  and  discharge  the  sebaceous  debris 
and  hairs  found  in  these  cavities  ;  the  cavity  usually  becomes  infected, 
and  the  contents  may  be  horridly  fetid. 


Fig.  337. — Diagram  showing  position  occupied  by 
thyroid  tumours  and  cysts  in  the  base  of  the 
tongue,  indicated  by  the  double  dotted  line. 


Foramen  caecum  ;  2,  hyoid  bone. 


LINGUAL    DERMOIDS  197 

In  a  case  undei  my  care,  a  French  boy  complained  oi  this  off< 
discharge,  but  at  first  nothing  could  be  detected  on  examination  of 
the  month,  ('loser  inspection,  however,  Bhowed  .1  few  fine  hairs  pro- 
jecting from  the  side  of  a  fistula  in  the  position  oi  the  submaxilla 
papilla.  A  probe  passed  into  a  deep  cavity  let  oui  a  quantity  oi  very 
offeiiM\''  Bebaceoue  matter;  an  attempt  was  made  to  destroy  the 
cyst  wall,  and  this  failing,  the  cyst  was  completely  dissected  out  after 
division  of  the   mandible. 

Treatment. — Dermoid  cysts  must  be  excised,  either  through 
the  open  mouth  or,  if  large,  by  an  incision  below  the  jaw  (Regnoli's 
incision,  p.  L'26).  As  a  rule  they  shell  out  easily  by  blunt  dissection, 
though  they  are  usually  adherent  to  the  hyoid  bone  at  one  point. 

Sometimes  great  difficulties  from  surrounding  inflammation  are 
encountered,  rendering  a  laryngotomy  or  a  tracheotomy  necessary  : 
while,  if  the  cyst  has  ruptured,  the  dissection  of  the  sinus  is  a  matter 
of  the  greatest  trouble,  and  may,  as  in  the  case  recorded  above,  neces- 
sitate division  of  the  jaw  at  the  symphysis.  The  whole  cyst  wall 
or  fistulous  track  must  be  removed,  or  the  operation  will  be  a  failure. 
The  cavity  should  be  plugged  with  iodoform  gauze,  kept  clean,  and 
allowed  to  heal  up  from  the  bottom. 

Lateral  dermoids  are  treated  in  the  same  way. 

Tubulo-Dermoids,  Thyro-Dermolds,  or  Thyro-Glossal 
Dermoids 

These  growths  are  found  at  the  back  of  the  tongue,  in  the  region 
of  the  foramen  csecum,  or  deeply  embedded  in  the  posterior  part  of 
the  tongue  substance.  When  situated  near  the  surface  they  are  more 
often  solid  than  when  placed  more  deeply.  As  in  the  case  of  the 
thyroid  gland  itself  we  meet  with  adenomas  in  which  there  is  no 
cystic  change,  and  with  others  in  which  the  whole  tumour  under- 
goes a  cystic  transformation,  so  in  the  thyroid  tumour  of  the  tongue 
it  is  a  mere  chance  which  variety  wall  occur. 

These  cystic  tumours  are  generally  regarded  as  retention-cysts 
of  the  thyro-glossal  duct,  and  as  such  are  infinitely  commoner  below 
than  above  the  hyoid  bone  ;  in  actual  fact,  however,  we  are  hardly 
justified  in  putting  this  interpretation  on  their  origin,  since  there  is 
no  evidence  to  show  that  the  thyro-glossal  duct  was  ever  a  functional 
canal  for  the  purpose  of  conveying  secretion  into  the  mouth  ;  it  is 
rather  the  track  of  the  developing  thyroid,  and  would  be  better  called 
the  thyro-glossal  tract,  along  the  course  of  which  aberrant  thyroid 
particles  may  develop  into  cysts  or  tumours.  The  thyro-gl<»-al 
tract,  indicated  in  Fig.  338  by  a  thick  black  line,  passes  from  the 
foramen  caecum,  through  the  base  of  the  tongue,  to  the  hyoid  bone. 
It  usually  nins  behind,  but  occasionally  in  front  of  this  bone,  and 


THE  TONGUE 


in  rare  instances  through  it.      Thence  it  extends  down  in  front  of 
the  thyroid  cartilage. 

When  these  thyroid  tumours  develop  at  the  base  of  the  tongue 
they  are  often  solid  and  consist  of  vascular  thyroid  tissue  exceedingly 
prone  to  bleed  ;  severe  and  even  fatal  haemorrhage  has  occurred 
spontaneously  or  as  the  result  of  incautious  puncture.     Cystic  change 

may  occur,  and  this  is  no 
doubt  the  origin  of  the 
so-called  blood  cysts  of  the 
tongue. 

Treatment. —  Thyro- 
glossal  cysts  should  be 
completely  excised ;  this 
entails  a  dissection  of  the 
tubular  canal,  which  may 
be  found  extending  from 
the  thyroid  gland  up  to, 
or  even  beyond,  the  hyoid 
bone.  Incomplete  removal 
is  always  followed  by  recur- 
rence. Although  it  is  rarely 
necessary  to  continue  the 
dissection  beyond  the  hyoid 
bone  into  the  tongue  sub- 
stance, the  operator  must 
be  prepared  to  do  this, 
even  dividing  the  hyoid 
bone  if  necessary. 

No  treatment  should  be 
undertaken  in  the  case  of 
the  solid  thyroid  tumours 
at  the  base  of  the  tongue, 
unless  they  are  the  cause 
of  trouble.  Not  only  is  an 
operation  for  their  removal 
attended  by  a  considerable 
amount  of  danger,  but  in  some  cases  these  tumours  consist  of  the  only 
functional  thyroid  tissue  wThich  the  patient  possesses,  and  removal 
of  them  has  been  followed  by  cachexia  strumipriva.  If,  however, 
they  give  rise  to  serious  hsemorrhage  from  ulceration,  or  difficulty  in 
swallowing  or  breathing,  they  must  be  removed.  When  projecting 
from  the  surface,  and  especially  if  somewhat  pedunculated,  they 
may  be  snared  off  with  a  cautery  wire. 

The  more  deeply  situated  tumours  must  be  dissected  out.     Rose's 


Fig.  338.- 


-Diagram  showing 
glossal  tract." 


thyro- 


i,  Thyro-glossal  tract  ;   i,  hyoid  bone. 


MAGROGLOSSl  \  199 

position  (p.  219),  the  bead  hanging  over  the  table,  may  be  sufficieo.1  in 
Borne  cases,  l>ut  in  others  the  uprighl  position  with  division  of  the 
mandible  will  give  better  a  Wain,  a  preliminary  laryngotomy 

may  be  advisable.  En  every  case,  rare  mu-i  be  taken  to  check 
all  bsamorrhage  and  to  Wing  the  edges  of  the  cavity  together  with 

deep    sun; 

After-treatment  as  in  operations  £01  cancer  musl  be  carried  out. 

Other  cystic  conditions  which  have  been  described  are 
mtuoous  cysts,  from  distension  of  the  mucous  glands,  and  parasitic 
cysts,  from  the  deposil  of  1  ercus  celhilosa  or  of  echinococcus 

sites. 

M  ACROGLOSSIA,    OR    ENLARGEMENT    OF    THE    TONGUE 

The  several  causes  of  enlargement  of  the  tongue  fall  convenientlv 
under  the  following  headings: — 

1.  Lymphangiomatous. 

2.  Muscular. 

3.  Inflammatory. 

4.  Syphilitic. 

5.  Mercurial. 

1.  Lymphangiomatous  Enlargement 

This,  the  most  usual  form  of  macroglossia,  is  caused  by  a  dilatation 
of  the  lymphatic  spaces,  with  subsequent  thickening  and  induration 
of  the  lingual  tissues.  The  condition  is  usually  congenital,  but  it 
is  not  invariably  present  at  birth  ;  in  some  cases,  indeed,  it  is  not 
noticed  until  several  years  after. 

Pathology. —  The  normal  lymph  spaces  of  the  tongue  (the 
anterior  three-fourths)  are  increased  in  size  and  in  number.  This 
change  has  generally  been  ascribed  to  some  obstruction  to  the  efferent 
lymphatics  of  the  tongue,  so  that  the  existing  spaces  become  distended. 
It  1-  not  by  any  means  clear  that  this  is  the  sole  cause,  and  from  the 
progressive  spread  of  the  disease  it  has  been  suggested,  with  a  con- 
siderable amount  of  reason,  that  there  is  an  actual  overgrowth  of 
the  lymph  spaces  and  tissues  in  the  tongue  substance,  constituting 
an  actual  lymphangioma  or  new  growth.  Hutchinson  suggested  the 
term  ,:  infective  lymphangioma,"  analogous  to  lupus  lvmphaticus,  to 
explain  its  progressive  course,  but  it  is  simpler  to  regard  the  condition 
as  comparable  to  nsevoid  or  angiomatous  growths  of  the  veins  and 
capillaries,  affecting  in  this  instance  the  lymph-  rather  than  the  blood - 
vascular  system. 

Yirchow  compared  the  disease  with  elephantiasis,  and  the  similarity 
is  great  ;  at  the  same  time,  the  occurrence  of  macroglossia  among 
the  sufferers  from  elephantiasis  Arabum  is  exceedingly  rare. 


2oo  THE   TONGUE 

Precisely  the  same  pathological  phenomena  will  he  observed  if 
the  lymphatic  tissues  of  a  part  enlarge  to  such  an  extent  that  the 
existing  lymphatic  vessels  are  unable  adequately  to  drain  the  region, 
as  if  those  vessels  were  the  site  of  an  obstruction  preventing  them 
Irom  draining  in  normal  circumstances.    , 

In  some  cases  a  definite  injury  has  preceded  the  development  of 
macroglossia.     Stone  records  a  case  of  this  kind. 

The  microscopic  appearances  have  been  carefully  described  by  Butlin, 
to  whom  we  are  indebted  for  the  following  accurate  account : — 

"  If  a  vertical  section  be  made  of  a  simple  lymphangioma,  the  lymphatic 
spaces  immediately  beneath  the  epithelium  are  dilated  ;  by  further  enlarge- 
ment the  lymph  space  bulges  towards  the  surface,  thinning  the  epithelium 
by  pressure  until  only  a  layer  of  corneous  epithelium  covers  the  surface. 
The  contents  of  the  space  are  lymph-serous  fluid  containing  numerous  white 
corpuscles. 

"  By  extension  between  the  muscular  fibres  and  fusion  of  the  lymph 
spaces  large  cysts  are  formed,  so  that  the  portion  of  the  substance  of  the 
tongue  invaded  has  a  honeycombed  look.  Around  these  dilated  lymphatic 
spaces  three  changes  take  place,  and  it  is  in  accordance  with  the  relative 
proportions  in  which  each  occurs  that  the  differences  found  in  advanced 
cases  are  due.  These  are — (a)  dilatation  and  new  formation  of  blood-vessels  ; 
(6)  inflammatory  changes  with  formation  of  fibrous  tissue  ;  (c)  new  growth 
of  lymphadenomatous  tissue. 

"  (a)  The  capillary  loops  between  the  vesicles  in  the  simple  form  develop 
into  arteries,  thin-walled,  coiled,  and  of  a  considerable  size.  The  veins  also 
increase  in  number  and  become  dilated.  Then  the  blood-vessels  rupture 
into  the  large  lymphatic  spaces,  which  become  distended,  partly  by  blood  - 
clot,  partly  by  circulating  blood.  In  this  way  is  produced  the  cavernous 
form  of  macroglossia  (Barker,  Hutchinson,  jun.). 

"  (b)  The  dilatation  of  the  lymph  space  is  accompanied  by  inflammation. 
Small  round  cells  infiltrate  the  connective  tissues,  and  tough  fibrous  tissue 
increases  and  slowly  surrounds  the  spaces.  The  inflammation  is  subject  to 
sharp  fluctuations,  a  marked  increase  accompanying  the  extravasation  of 
blood  ;  then  it  subsides,  but  to  recur  again  and  again.  With  each  attack 
there  is  a  further  formation  of  fibrous  tissue,  which  permanently  enlarges  the 
portion  of  the  tongue  affected,  and  gives  the  enlarged  tongue  a  tough  or  almost 
wooden  feeling,  varying  with  the  amount  of  cedema  in  the  fibrous  tissue. 

"  The  fibrous  tissue  presses  aside  the  muscular  fibres  and  causes  them 
to  degenerate,  so  that,  whilst  the  tongue  enlarges,  the  amount  of  muscular 
substance  is  being  continually  reduced,  until  it  disappears  altogether  from 
the  affected  portion  of  the  tongue.  The  section  shows  simply  fibrous  tissue 
with  a  variable  number  of  spaces  containing  either  lymph  or  blood. 

"  (c)  Small  round  cells  collect  in  the  connective  tissue  between  the 
muscular  fibres,  amongst  the  lymph  spaces  ;  and  between  the  cells  retiform 
tissue  may  be  met  with.  These  small  round  cells  are  not  replaced  by  fibrous 
tissue,  but  a  new  growth  goes  on  slowly  until  lymphadenomatous  masses 
are  produced.  A  macroglossia  may  even  terminate  by  the  development 
of  a  small  round-celled  or  lympho-sarcoma." 

Clinical  features. — The  first  symptom  which  attracts  atten- 
tion is  an  increase  in   the  sensitiveness  of   the  organ,  accompanied 


V 


*/ 


Lymphangioma  of  dorsum  of  the  tongue,  which 
was  beset  with  clear  vesicles,  between  which  were 
scarlet  capillary  loops  and  blood-filled  vesicles. 
A  few  of  the  vesicles  were  filled  with  opaque, 
white  material.  The  condition  was  associated 
with  a  capillary  naevus  involving  the  lower  lip 
and  about  half  an  inch  of  skin  surface  parallel 
to  the  muco-cutaneous  margin,  and  extending 
across  the  alveolar  margin  to  the  under  surface 
of  the  tongue,  where  there  were  some  dilated 
veins. 

(E.  Rock  Carlings  case.) 


Plate  87. 


MAGROGLOSSIA 

by  the  development  ol  minute  cysta  or  "blisters,"  which  readily 
rupture.  (Plate  87.)  At  firsl  only  a  portion  of  the  tongue  it  affected, 
l>ut  the  process  spreads  until  the  whole  organ  i-  attacked.  From  time 
to  time  there  are  outbreaks  of  acute  inflammation,  which  Leave  the 
tongue  larger  and  firmer  than  before. 

At  first  the  tongue  is  concealed  within  the  mouth,  and  Bhows,  on 
inspection,  general  enlargement  with  hypertrophy  of  the  papillae; 
gradually,  however,  with  the  increasing  size  there  is  difficulty  in  retain- 
ing it  within  the  oral  boundaries,  the  saliva  dribbles  away,  and  the 
tongue  protrudes,  its  surface,  from  exposure  to  the  air,  becoming  hard, 
brown,  cracked  and  fissured.  Progressively  the  bones  of  the  oral 
cavity  become  affected;  and  in  some  cases,  even  alter  proper  treat- 
ment of  the  affected  organ,  closure  of  the  jaws  may  be  impossible. 

Treatment  consists  in  freely  removing  part  of  the  mean  by 
means  of  a  V-sliaped  cut,  and  suturing  the  edges  of  the  wound  togel  her. 
A  sufficient  amount  should  be  removed  to  allow  the  tongue  to  lie  easily 
within  the  mouth;  and  at  the  same  time  the  operator  must  bear  in 
mind  that  he  is  dealing  with  a  form  of  new  growth,  and  he  should 
therefore  endeavour  to  cut  wide  of  the  morbid  tissue,  otherwise  recur- 
rence in  the  stump  is  likely  to  ensue.  The  operation  is  attended  by 
profuse  bleeding,  and  steps  must  be  taken  to  deal  promptly  with  the 
haemorrhage. 

In  the  case  of  very  young  children  it  may  be  wise  to  postpone 
the  operation  for  some  years,  as  its  performance  has  been  fatal.  The 
child  should  be  spoon  fed — it  cannot  suck — until  sufficiently  strong 
to  stand  what  may  be  a  formidable  surgical  procedure,  and  then 
subjected  to  the  operation. 

2.  Mtjsctjlab  aIacroglossia 

A  true  muscular  hypertrophy,  in  which  there  is  an  increase  in 
number  and  size  (Helbing)  of  the  muscular  fibres,  is  occasionally 
seen.  Such  a  condition  may  occur  in  a  normal  individual,  the  "  lingua 
vituli:';  more  usually  it  is  met  with  in  cretins  and  congenital  idiots. 
In  some  cases  the  enlargement  may  be  unilateral.  It  may  be  asso- 
ciated with  abnormal  enlargement  of  other  parts  of  the  body,  and  is 
therefore  part  of  a  gigantism  or  increased  growth  of  the  individual, 
probably  the  effect  of  some  obscure  nervous  influence. 

Treatment. — The  activity  of  the  treatment  must  depend  upon 
the  amount  of  inconvenience  resulting  from  the  deformity.  Treat- 
ment is  not  to  be  undertaken  so  readily  as  in  the  former  vari 
since  the  progress  of  the  growth  is  slow  and  there  are  none  of  the 
characteristic  features  of  a  "new  growth"  present.  Occasionally  the 
two  forms  are  combined,  in  which  case  early  radical  treatment  is 
indicated. 


202  THE   TONGUE 

If  operation  becomes  advisable  in  the  pure  muscular  variety,  it 
should  consist  in  removal  of  a  wedge-shaped  piece  of  tongue,  rather 
than  in  ligation  of  the  lingual  arteries — a  method  which  is  neither 
certain  nor  safe. 

3,  4,  5.  Inflammatory,    Syphilitic,   and   Mercurial 
Enlargements 

Inflammatory  enlargement  is  merely  the  result  of  an  acute  glossitis, 
after  which  a  large  indurated  area  may  be  left. 

Syphilitic  hypertrophy  has  been  considered  in  connexion  with 
syphilitic  parenchymatous  glossitis  (p.  194).  The  condition  calls  for 
no  special  treatment. 

With  regard  to  mercurial  enlargement,  it  should  be  remembered 
that  excessive  use  of  mercury  in  syphilis  tends  to  exaggerate  any 
existing  hypertrophy,  and  that  the  drug  may  even  produce  an 
inflammatory  enlargement  by  its  own  action. 

INNOCENT   TUMOURS 

The  tongue  is  rarely  the  seat  of  a  simple  growth — a  marked  contrast 
to  its  ready  tendency  to  undergo  malignant  change.  Innocent  tumours 
of  many  varieties  have  been  described,  such  as  lipomas,  recognized 
by  their  yellowish  colour  when  superficial  ;  fibromas ;  chondromas  ; 
localized  or  general  lymphangiomas  ;  neuro- fibromas  ;  myomas  of  both 
striped  and  unstriped  types  ;  amyloid  masses  in  the  subjects  of  chronic 
bronchitis  and  emphysema  ;  and  even  osseous  tumours  and  those  of  a 
teratoid  nature.  Many  of  these  growths  are  of  the  greatest  rarity, 
and  may  be  regarded  as  being  more  of  pathological  interest  than  of 
clinical  importance.  In  general  they  will  be  treated  by  removal  if 
the  tumour  appears  to  be  a  source  of  discomfort  or  danger 

Vascular   Tumours 

On  the  other  hand,  the  vascular  tumours  are  not  only  a  good  deal 
commoner  than  the  preceding,  but  since  they  may  be  the  source  of 
dangerous  haemorrhage  they  must  be  specially  considered. 

Among  the  vascular  tumours,  examples  of  arterio-venous  aneurysm 
have  been  met  with,  as  the  result  of  injury.  They  have  occurred 
usually  on  the  floor  of  the  mouth,  and  have  been  treated  by  ligation 
of  the  lingual  arteries.  A  few  instances  of  cirsoid  aneurysm  have 
been  recorded  ;  one  half  of  the  tongue,  in  the  published  cases,  being 
occupied  by  large  tortuous  arteries  which  bled  violently  as  the  result 
of  injury. 

N.EVI 

Nsevi,  both  capillary  and  cavernous,  are  much  more  common. 
The  capillary  form  may  be  congenital  in  origin,  or  may  appear  later, 


VASCULAR    I  UMOl   RS 

possibly  as  the  resull   of  injury.     Capillary  naevi   bleed   readily  and 
profusely,  and  in  this  respect  are  Bimilar  to  the  Bmall  bul  dang 
oapillary  haemorrhoids  described  by  Allingham. 

The  cavernous  naevi,  usually  found  on  the  anterior  pari  of  the 
tongue,  may  attain  Borne  Bize,  and  may  be  associated  with  a  similar 
state  of  the  lip  and  cheek.  They  are  quite  painless,  and 
rule  circumscribed,  but  they  have  an  unfortunate  tendency  to 
increase  in  size,  and  are  liable  to  bleed  profusely  if  injured.  A 
cavernous  nevus  is  recognized  by  its  dark  colour  and  sofl  consist- 
ence, in  addition  to  the  enlargement  of  the  vessels  in  the  neigh- 
bourhood. 

Treatment. — NTaevi  should  receive  active  treatment,  as  there 
is  always  a  risk  of  severe  bleeding,  which  cannot  in  all  eases  be 
readily  controlled.  Capillary  <»r  even  small  cavernous  naevi  should 
be  treated  by  the  galvano-cautery — the  point,  at  a  dull-red  heat. 
being  thrust  deeply  into  the  spongy  tumour.  The  application  must 
be  repeated  until  the  blood  spaces  are  finally  obliterated.  Electro- 
lysis is  often  of  use  in  these  cases. 

In  more  extensive  and  diffuse  cases  excision  is  indicated,  by  means 
of  a  wedge-shaped  cut  placed  well  outside  the  line  of  the  nsevus,  care 
being  taken  to  secure  the  larger  vessels  as  they  are  cut.  As  a  pre- 
liminary measure.,  one  or  both  lingual  arteries  may  require  ligation. 

VARICOSE    VEINS 

May  be  met  with  in  the  tongue  as  in  other  parts  of  the  body  ;  some 
degree  of  varicosity  is  usually  associated  with  naevi.  As  a  rule  no 
treatment  is  required,  especially  when  the  posterior  part  of  the  organ 
is  affected,  as  there  is  little  danger  here  of  injury  and  bleeding.  In 
the  anterior  part,  if  increasing  in  size  they  should  be  treated  as  naevi, 
of  which,  very  often  they  form  a  part. 

Papillomas 

These  growths  are  found  chiefly  on  the  dorsum,  and  are  in  main- 
oases  congenital.     They  may  be  single  or  multiple. 

Irritation  unquestionably  plays  a  part  in  the  production  of  a  certain 
number  of  papillomas.  One  variety,  found  on  the  side  of  the  frsenum 
from  contact  with  the  incisor  teeth  in  whooping-cough,  appear-  to 
follow  the  development  of  an  ulcer  which  is  commonly  present  in  this 
situation. 

Tongues  which  are  the  seat  of  chronic  superficial  glossitis  are 
prone  to  develop  large  sessile  papillomas,  which  must  be  regarded 
as  examples  of  local  irritative  hypertrophy. 

Warty  growths  also  occur  in  syphilis. 

Treatment. — Papillomas  should  be  excised  or,  if  small,  destroyed 
completely    by   the    galvano-cautery.     The    inflammatory   papillomas 


2o4  THE   TONGUE 

are  unquestionably  liable  to  become  cancerous  ;  indeed,  it  is  sometimes 
impossible  to  distinguish  clinically  between  the  simple  tumour  and 
one  that  has  already  undergone  a  malignant  change.  They  should 
be  removed  by  elliptical  incisions  which  pass  deeply  into  the  tongue, 
and  the  edges  of  the  wound  should  be  sutured. 

MALIGNANT   TUMOURS 

Sarcoma  x 

Primary  sarcoma  of  the  tongue  is  rarely  met  with,  and  probably 
many  of  the  recorded  cases  do  not  properly  fall  under  this  heading. 
Microscopically  the  tumour  may  consist  of  round  or  spindle  cells, 
and  in  most  cases  there  is  a  very  well-marked  history  of  injury  or 
prolonged  irritation. 

The  degree  of  malignancy  in  the  recorded  cases  varies  so  enor- 
mously that  it  is,  perhaps,  too  early  yet  to  speak  with  decision  of 
the  diagnosis  and  treatment  of  sarcoma  of  the  tongue. 

In  some  cases  the  growth  appears  distinctly  encapsuled,  as  do 
sarcomas  elsewhere  in  the  body ;  in  other  cases  the  tongue  is  exten- 
sively invaded  and  the  growth  soon  spreads  to  the  lymphatic  glands. 

Lympho-sarcomatous  tumours  originating  in  the  lymphoid  tissue 
at  the  base  of  the  tongue  have  been  described,  and  seem  to  form  the 
most  malignant  variety.  The  large  round-celled  tumour  grows  much 
more  slowly,  while  slowest  of  all  is  the  fibro-sarcoma,  that  patho- 
logical cross-breed,  midway  between  the  fibroma  and  the  malignant 
growth.  • 

With  regard  to  treatment,  we  may  repeat  what  has  been 
said  above  in  connexion  with  simple  tumours.  All  new  growths  of 
the  tongue  should  be  removed.  If  the  rate  of  growth  of  a  tumour 
suggest  a  sarcomatous  nature,  or  if  there  be  recurrence  after  removal 
of  a  doubtful  tumour,  an  attempt  should  be  made  to  extirpate  the 
disease  by  cutting  widely  into  the  healthy  tissues  beyond  the  limits 
of  the  growth.  Glandular  involvement,  which  has  been  a  not  infre- 
quent concomitant  in  reported  cases,  will  be  a  contra-indication  to 
operative  treatment,  unless  there  be  a  good  prospect  of  getting  wide 
of  the  disease. 

Endothelioma,  or  Endothelial  Sarcoma  x 

Tumours  of  this  nature  starting  in  the  lymph  spaces  or  blood- 
vessels of  the  tongue  have  been  described  by  Eve  and  others. 
They  appear  to  vary  much  in  malignancy,  in  some  instances  growing 
slowly  and  causing  a  local  invasion  only.  At  the  present  time 
much  uncertainty  exists  as  to  the  exact  nature  of  some  of  the 
tumours  which  have  been  described  as  endotheliomas.  Here,  as 
1  See  also  Vol.  I.,  p  498. 


ENDOTHELIOMA     CARCINOMA 

elsewhere,  there  appeals  bo  be  a  growing  tendency  <>n  the  pari  of 
pathologists  to  classify  as  endotheliomas  many  of  the  growths  which 
have   been   hitherto  accepted   as  carcinomas.     Only  one  instance  ol 

the  kind  has  conic  under  my  notice  :    a  nodular  tumour,  unaccompanied 

by  marked  ulceration,  occupying  the  posterior  pari   of  the  righl 

of  the  tongue  in  a  man  of  60,  was  removed  locally  and  submitted  to 

microscopical  examination;  the  report  stated  that   the  structure  was 

very  unlike  carcinoma,  and  that    the  condition   was  one  of  endothelial 

sarcoma.  The  patient  refused  the  extensive  operation  thai  was 
proposed. 

More  information  is  still  required  on  this  subject,  the  chief  difficulty 
at  present  being  our  inability  to  distinguish  with  certainty  by  micro- 
scopical examination  between  connective-tissue  and  epithelial  cells. 

Carcinoma  x 

Pew  parts  of  the  body  are  so  susceptible  to  malignant  change  as 
the  tongue,  and  in  no  position  is  its  occurrence  more  distressing  to 
the  patient,  or  more  trying  to  the  surgeon,  although  at  first  sight  it 
would  appear  more  favourable  to  radical  treatment  than  growths  in 
many  other  situations. 

Of  all  cases  of  cancer  in  the  male  sex,  about  8  per  cent,  are  cases  of 
cancer  of  the  tongue,  according  to  the  figures  given  by  Butlin  and 
Jessett ;  while  on  comparing  the  relative  frequency  of  the  dise 
in  the  two  sexes,  allowing  for  some  slight  variations,  the  figures  work 
out  at  85  per  cent,  males  to  15  per  cent,  females.  This  greater  fre- 
quency in  the  male  sex  is  no  doubt  due  to  the  fact  that  the  precancerous 
states  induced  by  irritation  and  disease  are  commoner  in  the  male 
than  in  the  female. 

Although  the  "  cancerous  "  age  may  be  taken  as  beginning  at  40, 
cases  of  very  malignant  cancer  have  been  recorded  in  quite  young 
subjects — Variot  has  recorded  a  case  in  a  boy  of  11,  Billroth  in  a 
patient  of  18 ;  while  out  of  290  cases  recorded  by  Barker,  in  8  the 
ages  of  the  patients  lay  between  20  and  30.  Nor  does  old  age  confer 
immunity,  although  after  70  the  incidence  of  the  disease  is  rare. 
0.  Weber  has  observed  a  fatal  case  in  a  centenarian. 

Etiology.  Predisposing  causes — Whatever  the  future  may 
have  to  show  as  to  the  cause  of  cancer,  in  no  situation  do  the  pre- 
disposing causes  of  irritation  and  inflammation  play  such  an  important 
part  in  encouraging  the  disease  as  in  the  tongue  ;  and  until  our  know- 
ledge of  the  actual  cause  becomes  more  exact  we  must  devote  our 
attention  specially  to  those  factors  which  influence  the  incidence  of 
a  cancerous  change. 

It  is  now  universally  acknowledged  that  the  chronic  conditions  of 
1  See  also  Vol.  I.,  p.  335. 


2o6  THE   TONGUE 

leucoplakia,  and  syphilitic  Assuring,  and  unhealed  ulceration  are  liable 
to  become  malignant.  A  tongue  which  for  years  has  been  in  an  un- 
healthy state,  and  in  which  there  has  been  an  irregular  proliferation 
of  epithelial  and  connective-tissue  elements,  is  exactly  the  kind  of 
soil  in  which  the  cancer  cell  grows  and  flourishes.  This  "precancerous 
condition,"  as  it  has  been  called,  has  attracted  wide  attention,  and  it 
is  now  recognized  that  chronic  patches,  inflammatory  papillomas,  or 
indurated  fissures  which  do  not  subside  under  appropriate  treatment 
should  be  dealt  with  surgically.  We  are  as  yet  ignorant  of  the 
cause  which  converts  these  wavering  tissues  into  actual  cancer,  but 
we  know  that  the  irritation  of  carious  teeth  and  ill-fitting  tooth-plates 
and  the  incautious  use  of  caustics  have  a  very  serious  effect.  Butlins 
dictum  with  regard  to  caustics  should  be  quoted  in  full :  "If  there  be 
one  thing  more  harmful  than  another  in  the  treatment  of  a  simple 
indolent  sore  and  affections  of  the  tongue  in  persons  over  30  years 
of  age,  it  is  the  application  of  a  strong  caustic." 

Smoking  has  always  been  credited  with  a  considerable  degree  of 
importance  in  the  production  of  cancer  of  the  tongue,  and  it  may 
act  by  first  producing  a  condition  of  leucoplakia,  then  by  additional 
irritation  urging  that  on  to  a  cancerous  stage.  It  is  probably  the 
kind  of  smoking  indulged  in  that  is  of  special  importance  ;  "  hot 
smoking  "  with  short  pipes,  and  especially  rough-stemmed  pipes,  such 
as  clays,  is  more  dangerous  than  other  forms. 

Syphilis  is  another  predisposing  cause,  not  only  from  its  tendency 
to  produce  chronic  inflammatory  conditions,  but  from  its  liability  to 
leave  thin,  unstable  scars  or  fissures  which  readily  become  the  seat 
of  carcinoma. 

The  position  with  regard  to  our  present  knowledge  of  the  etiology 
of  cancer  may  be  summed  up  as  follows  :  There  exists  under  normal 
circumstances  a  "  balance  of  power  "  between  the  epithelial  and  con- 
nective tissues  of  the  body,  possibly  between  individual  cells  also  ; 
in  parts  which  are  the  subject  of  chronic  inflammatory  processes,  or 
subjected  to  prolonged  irritation,  that  balance  is  disturbed,  either  in 
the  shape  of  abnormal  activity  conferred  on  one  cell  element,  the 
epithelial,  or  a  diminished  control  on  the  part  of  another,  the  con- 
nective-tissue. Then  comes  the  actual  exciting  cause,  which  we  have 
yet  to  discover,  whether  a  parasite  or  some  peculiar  inherited  property 
possessed  by  the  cells  ;  it  is  here  that  the  border-line  which  separates 
the  precancerous  from  the  cancerous  stage  is  passed,  a  border-line 
indistinguishable  by  the  clinical  eye  and  not  always  clearly  defined 
to  the  pathological.  From  now  onwards  it  is  an  unequal  fight.  The 
cancerous  epithelial  cells  are  pitted  against  the  resistant  power  of 
the  connective-tissue  cells,  and  the  victory  is  nearly  always  with  the 
former.     In  order  that  in  future  our  treatment  may  be  successful,  we 


LINGUAL   CARCINOM  \  207 

musl  operate  al  the  earliesl  possible  moment;  by  smgica]  activity 
in  the  unstable  precancerous  stage  we  may  hope  to  averl  a  malignanl 
catastrophe,  while  by  extensive  operations  along  modem  lines  when  the 
disease  baa  declared  itself  we  may  hope  to  improve  results  which  in 
the  past  have  been  indeed  deplorable. 

Pathology. — Most  cancers  "I  the  tongue  are  Bquamous-celled 
epitheliomas,  due  to  the  downgrowth  of  epithelial  columns  from  the 
Burface.  Steiner  has  recorded  a  case  <>t  columnar  carcinoma.  Starting 
from  the  surface,  the  cells  penetrate  between  the  muscular  fibres  in 

eries  of  vertical  columns  which  tend  to  anastomose  and  to  develop 
cell-nests;  it  is  the  presence  of  a  number  <>|  these  cell-nests,  due 
to  a  corneous  degeneration  of  the  central  cells  of  the  tubular  down- 
growth,  which  conclusively  denotes  a  cancer  on  section.  This  spread 
is  accompanied  by  an  active  proliferation  of  round  connective- 
sue  cells  at  the  periphery,  a  reaction  which  we  must  regard  as  in 
part  protective,  a  poor  attempt  to  limit  the  relentless  growth.  It  is 
the  connective-tissue  proliferation  which  produces  the  "  infiltration  :' 
of  the  tongue  substance,  and  is  also  responsible  for  the  fixation  of 
the  organ  that  occurs  at  a  later  date. 

The  superficial  cells  of  the  growth  degenerate  partly  from  lack  of 
nutrition,  partly  as  the  result  of  the  action  of  the  connective-tissue 
cells,  and  thus  give  rise  to  surface  ulceration.  Those  cases  where  the 
growth  appears  as  a  nodule  in  the  tongue  substance  are  examples  of 
delay  of  the  degeneration  and  consequent  ulceration. 

In  some  instances  the  growth  and  spread  of  the  epithelial  cells  is 
extraordinarily  rapid,  and  the  term  medullary  carcinoma  is  applied. 
In  others  the  process  is  slow  and  is  accompanied  by  the  develop- 
ment of  mature  fibrous  tissue  from  the  active  connective-tissue  cells 
surrounding  the  downgrowth  of  epithelium  ;  this  form  is  sometimes 
referred  to  as  the  scirrhous  type.  The  importance  of  these  varieties 
in  course  and  prognosis  will  be  considered  later. 

Glandular  infection. —  Sooner  or  later  the  cancer  cells 
detached  from  the  primary  focus  find  their  way  into  the  lymphatic 
channels  and  reach  the  glands  which  drain  the  region.  These  have 
been  already  described.  The  glands,  when  attacked,  increase  in  size, 
and  at  first  appear  as  hard  movable  masses,  tending  later  to  fuse  and 
to  undergo  two  special  changes  pecuhar  to  secondary  cancer  of  the 
tongue,  mouth,  and  lip,  namely,  cystic  degeneration  and  suppuration. 
The  cystic  change  is  mainly  the  result  of  necrosis  of  the  central  cells  ; 
suppuration  is  due  to  a  bacterial  infection  which  accompanies  the 
cancer  cells  to  their  destination  in  the  glands. 

Clinical  appearance  and  classification. — Cancer  of  the 
tongue  appears  in  a  number  of  different  forms,  the  variation  being 
due,  first,  to  the  primary  condition  of  the  organ  in  which  the  growth 


2o3  THE   TONGUE 

has   started  ;  secondly,  to  peculiarities  in  the  growth  itself ;   thirdly, 
to  the  amount  of  resistance  that  it  encounters  on  its  way. 

1.  Papillary  form. — Two  varieties  are  seen:  (1)  The  small 
indurated  papillomatous  cancer,  which  has  started  in  a  plaque  or 
neglected  leucoplakial  patch,  and  is  only  recognized  by  its  induration. 
Very  often  a  deep  fissure  can  be  seen  traversing  the  papillary  area. 
(2)  The  large  fungating  cauliflower-growth.  I  have  seen  two  marked 
cases  of  this  form.  The  appearance  at  first  sight  did  not  suggest  a 
cancer,  but  rather  a  benign  papilloma.  There  was,  however,  a  history 
of  rapid  growth,  and  the  mass  was  much  larger  and  whiter  than  is 
usual  with  the  simple  papilloma.  In  both  instances  there  was  a 
curious  absence  of  induration.  The  diagnosis  of  cancer  was  con- 
firmed by  microscopical  examination,  but  in  each  instance  there  was 
rapid  and  fatal  recurrence  after  operation.  I  regard  this  type  as 
exceptionally  malignant. 

2.  Nodular  form.  —  The  nodular  type  is  somewhat  rare.  It 
appears  as  a  hard  nodule  or  plaque  which  seems  situated  in  the  tongue 
substance,  closely  simulating  a  primary  chancre.  There  is  little  or 
no  ulceration,  because  the  degenerative  process  is  not  marked.  In 
a  case  of  this  kind  under  my  care  I  was  very  doubtful  of  the  diagnosis 
until  I  had  removed  the  mass  and  submitted  it  to  microscopical 
examination.  On  squeezing  the  mass  before  excision,  I  made  caseous 
matter  ooze  from  a  small  opening  on  the  surface,  and  thought  I  had 
to  deal  with  a  chronic  inflammatory  mass,  possibly  caused  by  a 
foreign  body.     The  pathologist's  report  left  no  room  for  doubt. 

3.  Ulcerous  form. — This  is  the  common  variety,  but  here  again 
the  ulcer  may  present  itself  in  a  number  of  different  guises,  depending 
upon  the  rate  at  which  it  spreads,  the  presence  or  absence  of  an  active 
bacterial  infection,  or  upon  the  particular  type  of  ulcer,  such  as  a 
dental  ulcer,  on  which  the  cancerous  process  has  been  grafted. 

The  chief  characteristics  of  the  typical  cancerous  ulcer  are  as 
follows  :  It  is  usually  situated  at  the  side  of  the  tongue,  very  commonly 
at  the  posterior  part,  and  the  tongue,  being  fixed  by  the  infiltration, 
is  protruded  with  difficulty.  In  advanced  cases  the  patient  may  not 
be  able  to  open  his  mouth  widely.  There  is  an  abundance  of  saliva, 
which  runs  away  when  the  mouth  is  opened. 

The  surface  of  the  ulcer  is  usually  foul  and  covered  with  food, 
bacteria,  and  epithelial  debris  ;  the  edges  are  raised,  and  for  a  distance 
of  a  quarter  of  an  inch  or  more  the  thickened  epithelium  of  the  margin 
stands  out  as  a  white  or  yellowish-white  band  from  the  surrounding 
normal  cuticle.  This  peripheral  thickening  of  the  epithelium  is  present 
in  epitheliomas  of  the  lip,  and  is  an  important  detail. 

On  passing  the  finger  over  and  round  the  ulcer  the  edges  feel 
hard    and   indurated,    like    cartilage,   while   a  mass  can   be   detected 


LINGUAL   CARCINOMA 

in   the    tongue   Bubstance    continuous  with    the   ulcer.     The   sui 
bleeds  readily  on  examination. 

If  the  mouth  has  been  kepi  clean,  and  especially  if,  with  the  idea 
of  oleaning  up  a  dental  ulcer,  washes  have  been  ordered  or  iodide  of 
potash  prescribed,  the  appearance  may  be  different. 

The  surface  of  a  Eoul  ulcer  readily  cleans  under  proper  treatment, 
and  sloughs  and  offensive  smell  may  both  be  absent. 

4.  The  fissured  form  commences  in  the  cracks  or  clefts  left  after 
chronic  glossitis,  syphilis,  ami  more  rarely  tuberculosis.  Fissured 
cancer    is    uncommon,   and    is    difficult    to    diagnose    in    the    early 

3 es  :  the  chief  features  being  the  callous  character  of  the  ulcer 
and   the   induration  of  its  edges. 

5.  Indurative  form  ('"wooden  tongue").  —  The  whole  tongue 
becomes  peculiarly  fixed,  shrunken,  and  hard,  often  as  the  result  of 
previous  inflammatory  changes.  The  amount  of  ulceration  present 
may  be  quite  slight,  and  may  be  overlooked  when  situated  at  the 
posterior   part. 

An  attempt  has  thus  been  made  to  describe  the  chief  clinical 
varieties  of  the  disease;  and  it  may  be  well  to  emphasize  again  the 
fact  that  ulceration,  although  usual,  does  not  invariably  accompany 
the  development  of  cancer. 

6.  Double  epithelioma. — Diffuse  and  hypertrophic  forms  have 
been  described. 

Situation. — Any  part  of  the  tongue  may  be  attacked,  but  the 
disease  is  much  commoner  in  the  anterior  two-thirds.  The  sides  of 
the  tongue,  more  liable  to  irritation,  are  also  more  liable  to  cancer. 
I  have  seen  a  great  many  cases  at  the  junction  of  the  anterior  faucial 
pillar  with  the  side  of  the  tongue. 

Cancers  at  the  back  of  the  tongue  are  easily  overlooked  ;  they 
spread  rapidly  and  deeply,  and  are  difficult  to  deal  with. 

Epithelioma  may  affect  the  tongue  from  surrounding  structures, 
such  as  the  floor  of  the  mouth,  tonsil,  and  lip,  but  these  will  be  con- 
sidered under  their  respective  headings. 

Symptoms. — Pain,  salivation,  bleeding,  inability  to  open  the 
mouth,  are  some  of  the  symptoms  which  cause  a  patient  to  seek:  relief. 
Pain  often  referred  to  the  ear  is  common  in  cancers  at  the  back  of 
the  tongue.  The  pain  in  the  ear  is  generally  regarded  as  referred 
from  the  lingual  to  the  auriculo-temporal,  but  it  may  well  be  con- 
nected with  the  course  of  the  glosso-pharyngeal  or  vagus,  especially 
the  latter,  since  similar  auricular  pain  is  common  in  cancer  of  the 
larynx.  Sometimes  pain  is  curiously  absent,  and  the  patient  comes 
dissatisfied  with  the  non-healing  of  an  ulcer,  or  delays  seeking  advice 
until  a  large  fungating  mass  involves  the  tongue.  Salivation  is  usually 
present  and  troublesome. 


2io  THE   TONGUE 

Inability  to  open  the  mouth  is  a  late  symptom  and  clue  to  the 
infiltration  spreading  back  into  the  tonsillar  region  ;  rarely  it  is  due 
to  reflex  pain. 

Haemorrhage  in  the  early  stages  is  always  slight,  and,  even  when 
the  growth  is  advanced,  serious  haemorrhage  in  the  primary  focus 
is  rare,  though  it  is  more  common  and  fatal  from  the  secondary 
deposits. 

Course. — The  disease,  when  once  established,  progresses  steadily 
to  a  fatal  termination  within  one  or  two  years,  unless  arrested  by 
operative  treatment.  In  some  cases,  death  has  occurred  as  early  as 
five  months  from  the  first  appearance  of  the  disease. 

To  the  gradual  but  definite  spread  of  the  lingual  growth  there  is 
added,  sooner  or  later,  the  glandular  infection.  No  exact  period  can 
be  laid  down  before  which  it  may  be  safe  to  assume  that  the  glands 
have  escaped  ;  it  is  again  a  question  of  resistance  .and  virulence.  The 
natural  resistance  which  the  tissues  are  able  to  offer  to  the  spread  of 
the  growth  may  prevent  lymphatic  permeation  for  several  months  ; 
on  the  other  hand,  a  growth  of  high  malignancy  fostered  on  a  fertile 
soil  may  spread  with  appalling  celerity  to  the  glands  and  involve 
them  extensively.  Nor,  again,  are  we  able  accurately  to  determine 
the  state  of  the  glands  on  clinical  examination.  In  the  early  stages 
of  their  infection  the  small  shotty  glands  are  quite  out  of  reach  of  the 
examining  finger. 

It  is  true  that  a  growth  accompanied  by  sloughing  and  ulceration 
will  give  rise  early  to  inflammatory  glandular  enlargement,  an  enlarge- 
ment which  may  subside  after  the  growth  has  been  removed,  but  we 
cannot  with  any  safety  rely  on  this  to  help  us,  for  cancer  cells  may 
have  settled  in  the  glands  at  the  same  time  as  the  bacteria,  and,  if  the 
glands  are  left,  these  cells  will,  by  their  progressive  development, 
ultimately  render  an  operation  for  their  removal  imperative — an 
operation  which  perhaps  has  been  most  unwisely  deferred. 

In  all  cases  in  which  cancer  in  the  tongue  is  proved  we  must  assume 
infection  of  the  glands. 

If  the  case  is  seen  too  late  for  operative  treatment,  there  is  nothing 
to  look  forward  to  but  a  horrible,  lingering  agony,  to  which  the  final 
complication  comes  as  a  great  relief.  Progressively,  the  ulcer  increases 
in  size ;  food  is  taken  only  with  difficulty ;  pain,  fetor,  and  salivation 
combine  to  render  the  patient  unbearable  to  himself  and  to  those 
who  surround  him  ;  the  glands  enlarge,  break  down  and  ulcerate  ; 
and  death  is  happily  ushered  in  by  a  fatal  haemorrhage  or  a  low  form 
of  pneumonia.  Probably  few  have  watched  the  final  struggles  of 
these  exhausted  patients,  and  only  those  who  have  can  realize  the 
extent  of  the  misery  which  the  disease  entails.  It  is  well  that  this 
should  be  fully  appreciated  before  a  decision  is  arrived  at  that  a  case 


LINGU  \i    < :  \kci\<  >\i  \ 

is  inoperable,  sine.',  even  if  only  the  primary  growth  can  be  dealt  with, 
death  from  glandular  recurrence  is  infinitely  Less  painful. 

Tin-  rapid  spread  of  lingual  carcinoma  has  been  explained  by 
Beidenhain  as  due  i<>  the  contractions  of  the  lingua]  muscles,  which 
are  constantly  forcing  on  the  cancer  cells ;  but,  aparl  from  the  glands, 
dissemination  to  a  wide  extent  is  uncommon,  probably  because  the 
patienl  dies  from  tin'  lingual  or  glandular  disease  before  extensive 
metastases  can    form. 

Diagnosis — A  certain  diagnosis  in  cases  of  early  carcinoma  of 
the  tongue  is  impossible  withoul  the  aid  of  microscopical  examination. 
In  the  more  advanced  cases,  the  pain,  induration,  thickened  epithelial 
margin,  fixation,  and  glandular  enlargement,  all  indicate  malignanl 
disease.     The   chief  difficulty   will   be   experienced    in    extinguishing 

between  carcinoma  on  th ie  hand,  and  a  chronic  ulcer  from  irritation, 

gummatous  ulcer,  and  perhaps  more  rarely  tuberculosis,  on  the  other. 
A  careful  examination  should  be  made  of  the  mouth,  to  see  whether 
a  local  cause,  Buch  as  a  rough  carious  tooth  or  an  ill-fitting  tooth- 
plate,  exists.  Careful  inquiries  into  the  history  should  be  made,  and 
the  lungs  should  be  thoroughly  examined.  If  this  investigation  does 
not  throw  any  light  upon  the  case,  no  time  should  be  wasted  before 
making  a  careful  microscopical  examination  of  the  margin  of  the 
growth  ;  for  this  purpose  it  may  be  sufficient  to  snip  off  a  small  piece 
after  the  part  has  been  painted  with  a  5  per  cent,  solution  of  cocaine. 
but  I  am  of  the  opinion  that  it  is  far  wiser  to  cut  out  a  fair  piece  of 
growth  and  adjoining  tissue.  I  have  so  frequently  seen  the  futility 
of  trying  to  form  an  opinion  from  a  small  piece  of  shrunken  tissue. 
A  mere  scraping  of  the  growth  is,  in  my  view,  insufficient,  even 
though  it  show  a  number  of  cell-nests ;  in  order  to  be  certain  we 
must  study  the  epithelial  changes  in  relation  to  the  adjoining  con- 
nective tissues. 

It  has  been  argued  that  such  an  examination  tends  to  disseminate 
the  growth,  and  to  excite  it  into  abnormal  activity.  Personally  I 
place  no  reliance  on  this  statement,  since,  once  it  has  been  decided  to 
examine  a  doubtful  growth,  a  radical  operation  can  be  undertaken 
almost  at  once  if  the  preparation  of  the  section  is  hurried.  I  should 
regret  it  extremely  if  I  had  performed  one  of  the  extensive  modern 
operations  for  cancer  of  the  tongue  on  insufficient  grounds. 

On  the  other  hand,  no  time  should  be  wasted  in  trying  potassium 
iodide,  unless  indeed  the  clinical  condition  of  the  ulcer  and  the  past 
history  should  strongly  favour  syphilis.  It  is,  unfortunately,  a 
common  line  of  treatment  to  combine  the  administration  of  iodide 
of  potash  with  the  application  of  antiseptic  lotion-  to  the  ulcer. 
Under  this  combination  cancerous  ulcers  will  improve,  the  fetor 
and  pain  diminish,   and   even   the   induration   will   subside   to   -one- 


212  THE   TONGUE 

extent.  Lulled  into  a  state  of  false  security,  patient  and  surgeon 
allow  valuable  time  to  elapse,  and  then,  when  the  true  state  of 
affairs  is  realized,  the  ulcer  is  probably  much  more  advanced,  and 
less  favourable  for  treatment  than  it  was  at  first. 

If  there  is  an  obvious  source  of  irritation,  let  it  be  removed,  and 
let  the  ulcer  be  treated  with  a  mild  antiseptic  and  occasional  touches 
of  chromic  acid  ;  strong  caustics  arc  never  to  be  applied.  If  there 
is  no  obvious  improvement  in  ten  days,  remove  a  piece  of  the  margin 
for  examination  as  suggested  above. 

Tuberculosis  should  be  less  frequently  confused  with  cancer,  as 
it  is  much  rarer  and  occurs  in  younger  subjects,  who  are  generally 
sufferers  from  pulmonary  tubercle  ;  Nedopil,  however,  cut  out  several 
tuberculous  ulcers  under  the  impression  that  they  were  cancerous.  As 
this  is  a  recognized  treatment  for  tuberculous  ulcers,  no  harm  is  done, 
provided  nothing  very  extensive  is  attempted.  In  a  case  of  my  own,  in 
a  man  of  65,  a  large  ulcer  sprang  from  the  side  of  the  tongue,  crossed 
the  mouth,  and  involved  the  lower  jaw  extensively.  There  were  hard, 
enlarged  glands  in  the  submaxillary  triangle.  All  who  saw  him  agreed 
that  the  condition  was  malignant,  and  the  general  appearance  certainly 
favoured  this  diagnosis.  I  removed  the  growth  and  the  glands  at 
one  sitting,  and  he  did  very  well,  recovering  completely  ;  but  further 
microscopical  examination  showed  that  the  growth  and  glands  were 
tuberculous. 

Prognosis.  —  Unless  a  lingual  cancer  is  operated  upon,  death 
is  certain.  Unfortunately,  the  operative  results  still  leave  much  to 
be  desired.     They  will  be  considered  later. 

Treatment- — Cases  of  carcinoma  which  come  for  treatment 
fall  into  four  main  groups  : — 

1.  The  condition  is  inoperable  ;  it  is  not  reasonable  to  attempt 
to  remove  even  the  primary  growth  ;  palliative  measures  alone  must 
be  employed. 

2.  The  condition  is  too  advanced  to  permit  of  complete  extirpation, 
but  local  removal  of  the  primary  focus  may  be  attempted,  with  the 
view  of  prolonging  life  and  averting  some  of  the  horrible  terminal 
complications.  This  applies  especially  to  carcinoma  situated  in  the 
posterior  part  of  the  tongue. 

3.  There  is  a  good  or  reasonable  chance  of  clearing  away  the  disease. 
Here  each  case  must  be  judged  on  its  merits,  and  the  opinion  of 
different  surgeons  will  vary  as  to  what  may  be  considered  operable 
or  otherwise.  No  absolute  rules  can  be  laid  down.  Extensive  and 
fixed  glandular  metastases  will  contra-indicate  a  complete  operation. 
Extensive  local  spread  may  do  the  same,  but  with  the  knowledge  of 
the  certain  fatal  issue  and  its  attendant  sufferings  we  should  be  ready 
to  operate  on  all  but  the  most  hopeless. 


I  INGUAL   CARCINOMA  213 

I.  The  disease  is  very  early;  the  diagnosis  may  lie  doubtful,  and 
glandular  metastases  are  ao1  obvious. 

The  results  of  operative  treatment  up  to  the  present  nave  1101 
been  very  encouraging,  largely  owing  to  the  Ea<  1  thai  the  lymphatic 
spread  lias  only  recently  been  emphasized  and  appreciated.  The 
trend  of  modern  surgical  ••pinion  is  towards  a  tree  removal  of 
the  tongue  and  a  complete  removal  of  the  lymphatic  areas  thai 
drain    it.  s 

\-  a  preliminary  to  any  operative  treatment,  some  effort  should 
be  made  to  get  the  month  into  as  clean  a  Btate  as  possible.  Absolute 
asepsis  cannot  be  attained,  but  obviously  carious  teeth  shonld  be 
removed  or  filled,  the  others  should  be  scaled,  and  a  week  may  be 
spent  in  frequent  irrigation  of  the  oral  cavity.  The  best  solutions  for 
this  purpose  are  weak  permanganate  of  potash,  carbolic  acid  1-100, 
bicarbonate  of  soda  30  gr.  to  the  ounce,  or  peroxide  of  hydrogen 
5  vols.  I  recommend  carbolic  acid;  it  is  cleanly  and  sedative,  though 
slightly  painful  air  first.  A  solution  of  bicarbonate  of  soda  to  alternate 
with  the  carbolic  is  distinctly  useful,  as  it  is  a  solvent  of  the  mucus 
and  allays  acid  fermentation  better  than  do  acid  antiseptics.  Similar 
solutions  may  be  used  after  the  operation.  Formamint  lozenges  are 
valuable. 

I  advise  patients  to  brush  the  teeth  three  times  a  day,  and  to  wash 
the  mouth  out  well  every  hour  or  half-hour  while  they  are  in  the  house. 
At  the  same  time  it  is  not  necessary  to  confine  a  patient  to  the 
house  for  the  whole  week  ;  he  should  be  encouraged  to  go  out  and 
occupy  his  mind  as  far  as  possible  with  things  around  him.  These 
days  of  waiting  may  be  usefully  employed  in  training  him  to  the  use 
of  the  nasal  or  stomach  tube,  and  in  accustoming  him  to  swallow  from 
the  rubber  tube  attached  to  the  "  feeder." 

If  the  disease  is  advanced,  the  patient  should  rest  in  bed,  and  be 
fed  with  stimulating  foods,  strong  soups,  some  alcohol,  and  possibly 
nutrient  enemas. 

If  he  is  old  and  enfeebled,  injections  of  glucose  (6  per  cent.)  and 
normal  saline  should  be  given  per  rectum,  one  pint  every  four  hours 
during  the  two  days  that  precede  the  operation.  Glucose,  when  so 
administered,  has  a  powerful  stimulating  effect. 

I  have  had  no  experience  of  the  use  of  antistreptococcic  serum, 
and  cannot  appreciate  its  value  unless  it  is  known  that  the  wound 
is  infected  with  the  particular  group  of  streptococci  from  which  the 
serum  was  prepared.  The  blind  administration  of  these  serums 
seems  unscientific  and  unsatisfactory;  it  would  be  much  better,  in 
my  opinion,  to  take  a  few  cultures  from  the  mouth  beforehand,  and 
to  prepare  a  vaccine  for  any  obvious  growths  of  streptococci  and 
staphylococci. 


^14  THE   TONGUE 

Operative  Methods 

In  a  discussion  concerning  the  various  operative  procedures  for 
cancer  of  the  tongue  the  following  points  have  to  be  especially  con- 
sidered : — 

1.  A  preliminary  laryngotomy  or  tracheotomy. 

2.  The  preliminary  ligation  of  the  blood-vessels. 

3.  The  relative  order  in  which   the   growth   and   the    glands 

should  be  attacked. 

4.  The  amount  of  lingual  tissue  to  be  removed. 

1.  Should  a  preliminary  laryngotomy  or  trache- 
otomy be  done? — The  objects  which  have  induced  operators  to 
perform  this  initial  step  have  been  :  first,  to  prevent  blood  trickling 
down  into  the  lungs  during  the  performance  of  the  operation ; 
secondlv,  to  prevent  suffocation  from  the  falling-back  of  the  stump 
of  the  tongue  subsequently  ;  thirdly,  to  prevent  septic  pneumonia — 
the  pharynx  being  plugged  for  some  days,  the  patient  is  allowed 
to  breathe  only  through  the  artificial  opening. 

The  answer  to  the  question  must,  to  a  large  extent,  depend  upon 
the  nature  of  the  operation  to  be  attempted.  If  the  more  formidable 
lateral  operation  of  Kocher  is  selected,  a  preliminary  opening  of 
the  trachea  may  be  an  advantage,  as  a  large  wound  is  left  in  the 
mouth  and  neck  from  which  discharges  may  infect  the  lungs  unless 
the  wounded  area  is  kept  carefully  plugged.  There  are,  however, 
other  less  objectionable  measures  at  our  disposal,  and  there  is  at 
present   a  strong  opinion  against  the  performance  of  tracheotomy. 

In  the  milder  procedure  of  "Whitehead,  when  only  one  half  of  the 
organ  is  removed  by  the  intrabuccal  method,  even  a  preliminary 
laryngotomy  is  not  always  required.  Nor  is  it  necessary  in  the  cases 
where  the  median  method  of  Syme  is  chosen,  since  here  the  patient's 
head  is  propped  up,  the  jaw  is  divided  in  the  middle  line,  and  all  the 
blood  escapes  externally. 

Again,  when  the  vessels  are  secured  during  the  dissection  of  the 
glands,  the  final  stage  of  the  removal  of  the  tongue  is  accomplished 
without  an}'  bleeding  at  all,  and  in  these  circumstances  laryngotomy 
is  not  required. 

"Where  the  more  extensive  operations  are  attempted,  especially 
those  designed  to  remove  growths  situated  posteriorly,  I  am  strongly 
of  the  opinion  that  a  laryngotomy  should  be  performed,  the  entrance 
to  the  larynx  being  firmly  plugged  with  a  soft  marine  sponge.  There 
is  no  doubt  that  this  preliminary  step  enables  the  operator  to  act 
with  greater  deliberation  and  confidence. 

Laryngotomy  should  be  preferred  to  tracheotomy  on  account  of 
its  greater  simplicity  and  its  freedom  from  complications ;  but  if  the 


LINGUAL   CARCINOMA:    OPERATION 

operator  makes  his  opening  in   the  air-passage  with  the  idea  of  i 
venting  the  patient  from   breathing  air  which   has  passed  over  the 
oral  wound  before  ii  is  clean,  then  tracheotomy  and  no!  laryngotomy 

should  be  performed.  A  laryngotomy  tube  is  not  tolerated  for  any 
length  of  time,  and  I  advise  its  removal  either  at  the  end  of  the 
operation  or  not  later  than   the  following  day. 

The  introduction  into  the  practice  of  surgery  of  nasal  ansest  h- 
by   means   of   tubes   introduced   into   the   larynx  through  the  nai 
and    of    the    administration    of    ether    by  the   intravenous    method, 
may  do   much  to  render   these    preliminary  operations  unnecessary. 
Intravenous  anaesthesia  has  much    to  recommend    it,   especially  for 
extensive  operations  on  the  mouth. 

2.  Preliminary  ligation  of  the  blood-vessels. — Dawbarn 
of  Philadelphia  has  written  very  forcibly  on  the  subject  of  prelimi- 
nary or  temporary  ligation  of  the  blood-vessels  before  attempting 
an  extensive  removal  of  the  tongue,  and  before  operations  on  the 
mouth  and  jaws.  There  is  no  doubt  that  this  control  is  largely  to 
the  surgeon's  and  the  patient's  advantage,  though,  again,  the  per- 
formance of  this  step  must  depend  upon  the  particular  procedure  to 
be  attempted. 

If  the  surgeon  decides  to  attack  the  glands  in  the  neck  before  the 
disease  in  the  mouth,  usually,  when  the  glandular  involvement  is 
advanced,  the  external  carotid  and  its  branches,  the  lingual  and  facial, 
arc  exposed  in  the  course  of  the  dissection,  on  one  or  occasionally 
on  both  sides,  and  deliberately  ligatured,  the  carotid  being  secured 
between  the  lingual  and  superior  thyroid  branches.  The  removal 
of  the  tongue  may  conclude  the  operation,  as  mentioned  below  ;  or 
this  final  procedure  may  be  deferred.  The  objection  to  this  is  that 
there  is  considerable  chance  of  the  tongue  becoming  gangrenous  when 
its  blood  supply  has  thus  been  cut  off. 

The  old  operation  of  ligature  of  the  lingual  artery,  beneath  the 
hyo-glossus,  should  remain  only  as  a  dissecting-room  exercise,  and 
should  cease  to  occupy  any  place  in  the  surgery  of  lingual  cancel. 
In  cases  where  it  was  desired  to  perform  an  extensive  removal  of  the 
tongue  the  operation  failed  in  its  object,  as  the  vessel  was  often  cut 
through  on  the  proximal  side  of  the  ligature,  and  in  any  case  the 
dorsalis  linguae  branch  was  frequently  not  controlled. 

Ligation  of  the  external  carotid  and  its  branches  ensures  occlusion 
not  only  of  the  lingual  but  also  of  the  facial,  which  gives  branches 
to  the  tonsillar  region. 

Temporary  closure  of  the  common  carotid  is  practised  by  Crile 
in  his  extensive  "  block  dissection  "  of  the  neck,  and  will  be  considered 
later,  but  it  is  not  recommended,  as  the  consequences  of  closing  the 
vessel,  even  for  a  short  time,  have  been  very  serious. 


2i6  THE   TONGUE 

3.  Relative  order  in  which  growths  and  glands 
should  be  removed,  and  the  question  of  removing  the 
glands  from  the  opposite  side  of  the  neck. — There  is  much 
difference  of  opinion  on  these  points,  and  I  will  briefly  review  the 
chief  arguments  for  and  against  the  various  procedures. 

By  primary  removal  of  the  lingual  growth  the  mouth  can  be  got 
healthy  and  clean,  the  patient  relieved  of  pain,  and  when  he  has 
recovered  from  this  operation  the  glands  can  be  removed  by  a 
systematic  dissection. 

As  an  objection  it  is  urged  that  such  an  operation  does  not  remove 
all  the  infected  tissue,  since,  if  we  are  to  operate  here  on  the  same  lines 
as  are  practised  in  the  surgery  of  the  mamma,  the  growth  and 
lymphatics  should  be  removed  in  continuity. 

This  is  certainly  a  sound  objection,  but  it  has  been  met  with 
the  statements  (1)  that  lymphatic  infection  in  Ungual  cancer  is  by 
embolism  and  not  permeation,  and  that  the  portions  of  the  lymph 
system  left  between  the  tongue  and  the  glands  do  not  contain  cancer 
cells ;  (2)  that  the  operation  is  much  more  severe  if  both  glands  and 
growth  are  removed  in  continuity — the  cellular  tissue  of  the  neck 
is  put  into  free  communication  with  the  mouth,  and  various  septic 
complications  are  likely  to  arise. 

If  the  first  of  these  two  statements  is  correct — and  we  have  no 
evidence  in  its  favour — there  is  good  ground  for  separating  the  two 
operations.  Personally,  however,  from  the  study  of  sections,  I  think 
there  is  considerable  danger  of  leaving  some  portion  of  the  growth 
behind,  and  pathological  opinion  favours  the  idea  that  this  disease 
spreads  by  permeation  and  not  by  embolism. 

Lenthal  Cheatle  has  been  kind  enough  to  show  me  some  of 
the  work  he  has  done  in  connexion  with  lingual  cancer.  The  sections 
are  entirely  convincing,  and  they  show  a  steady  spread  of  the  growth 
by  permeation  between  the  muscular  fibres  of  the  hyo-glossus  in 
lateral  cancer,  of  the  genio-hyo-glossus  in  median  cancer.  Recurrence 
after  operation  results,  in  my  opinion,  from  such  infected  areas  being 
left  in  the  portion  of  the  tongue  attached  to  the  hyoid  bone,  from 
which  situation,  as  it  were  from  a  primary  focus,  the  growth  is 
disseminated  towards  the  glands.  The  tendency  of  the  growth  will 
be  to  spread  away  from  the  mouth,  and  this  accounts  for  the  fact 
that  recurrence  in  the  mouth  is  rare. 

With  such  evidence  before  me,  and  as  the  result  of  my  own 
experience,  I  have  no  hesitation  in  saying  that  the  soundest  opera- 
tion consists  in  removing  glands  and  tongue  simultaneously  through  a 
wide  incision  in  the  neck.  Particulars  of  the  operation  will  be  given 
later.  It  is  a  dangerous  procedure,  however,  when  both  sides  must 
be  attacked ;    but  when  only  one  side  is  attempted  it  is  very  satis- 


LINGUAL  CARCINOMA:    OPERATION  ->; 

factory    and    the    wound    heals    well,    if   care    bas    been    taken    in 
preparing  the  mouth. 

Many  surgeons  are  of  opinion  that,  baying  in  mind  the  risks  and 
dangers  of  the  operation  mentioned  above,  the  needs  of  the  case  are 
adequately  me1  by  removing  the  tongue  first  by  means  of  an  hum 
buccal  operation,  the  glands  being  dissected  oul  by  a  routine  dissection 
in  ten  days'  time.  Such  a  procedure  may  pass  as  satisfactory  in  early 
rases,  or  if  it  is  the  intention  of  the  surgeon  to  perform  a  palliative 
operation.     En  most  eases,  however,  it  must  be  regarded  as  incomplete. 

If  the  operation  must  be  performed  in  two  Stages,  especially  in  ad- 
vanced cases,  it  would  seem  better  to  dissect  the  triangles  of  the  neck, 
ligating  the  external  carotid  on  one  or  both  sides,  and  then  in  a  week 
or  so  to  remove  the  tongue  very  freely  by  some  intrabucca]  method. 

There  is  still  another  detail  for  consideration,  and  that  is  whether 
the  glands  should  be  removed  from  both  sides  of  the  neck.  As  before 
stated,  the  tendency  in  modern  surgery  is  to  progress  to  more  radical 
methods,  but  at  the.  same  time  these  methods  should  be  checked  by 
pathological  and  clinical  observations. 

It  will  be  seen  from  the  description  of  the  lymphatics  of  the  tongue 
(p.  165)  that  certain  vessels  near  the  middle  line  communicate  with 
the  glands  on  both  sides.  The  same  occurs  in  the  case  of  the  lymph- 
vessels  at  the  tip.  In  cancers  situated  near  the  middle  line  or  tip 
of  the  tongue,  both  triangles,  therefore,  should  be  attacked. 

Cancer  of  the  posterior  third  of  the  tongue  also  leads  to  rapid 
bilateral  glandular  infection,  and  in  these  cases  the  glands  must  be 
removed  from  both  sides  as  a  routine. 

Out  of  27  cases  of  lingual  cancer  carefully  examined  post  mortem 
by  Dr.  Kettle,  pathologist  to  the  Cancer  Hospital,  the  glands  were 
affected  on  both  sides  of  the  neck  in  11.  Out  of  6  cases  of  cancer 
in  the  floor  of  the  mouth,  both  sides  of  the  neck  were  attacked  in  5. 
Obviously,  therefore,  in  cancer  situated  in  the  floor  of  the  mouth  that 
is  presumably  near  the  middle  line,  the  glands  on  both  sides  must  be 
removed.  With  regard  to  other  cases  of  lingual  cancer,  when  but  a 
small  part  of  the  side  of  the  tongue  is  affected  it  will  be  sufficient 
to  remove  the  glands  on  the  affected  side  only,  but  they  must,  of 
course,  be  removed  even  if  the  disease  is  met  with  at  an  early  stage, 
and  although  they  may  shoiv  no  obvious  infection. 

In  more  extensive  cases  both  sides  must  be  operated  upon. 

In  clearing  away  the  glands  in  the  anterior  triangles  of  the  nock 
it  must  be  remembered  that,  in  order  efficiently  to  remove  those 
embedded  in  the  substance  of  the  submaxillary  salivary  gland,  this 
latter  must  be  sacrificed.  It  is  also  well  to  remember  that  at  least 
one  of  this  submaxillary  group  is  actually  on  the  face  at  the  anterior 
border  of  the  masseter. 


2iS  THE   TONGUE 

One  point  in  the  figures  supplied  by  Kettle  is  very  striking, 
and  that  is  the  rarity  of  anything  like  general  dissemination.  Out 
of  33  cases,  distant  dissemination  was  noticed  only  in  5  : — 

Axilla  and  bronchial  glands       .  .  .  .  .1 

Spleen      .........      1 

Lung         .........      1 

Lung  and  pleura,  4th  rib  .  .  .  .  .1 

Cutaneous  nodules  over  clavicle  .  .  .  .1 

It  may  be  argued  that  patients  with  lingual  cancer  die  before  the 
period  of  general  dissemination  is  reached,  these  cases  thus  differing 
from  cases  of  mammary  cancer  ;  but  it  is  certainly  strildng  that  in 
40  per  cent,  of  fatal  cases  the  glands  on  both  sides  of  the  neck  are 
affected,  and  it  suggests  the  lines  on  which  further  research  is  needed 
and  along  which  operations  should  proceed. 

4.  The  amount  of  lingual  tissue  to  be  removed. — 
By  the  ordinary  intrabuccal  operation  of  Whitehead  only  that  portion 
of  the  tongue  that  is  covered  with  mucous  membrane,  or  little  more, 
is  removed  ;  and,  as  Cheatle  very  truly  says,  the  tongue  does  not 
merely  consist  of  the  part  that  is  visible  in  the  mouth,  but  of  a  con- 
siderable extra  buccal  portion  extending  to  the  hyoid  bone.  It  would 
be  regarded  as  an  example  of  the  most  imperfect  surgery  if  a  surgeon 
were  locally  to  excise  a  carcinoma  of  the  breast  or  a  carcinoma  of 
the  cervix  uteri ;  and  so,  in  cases  of  lingual  cancer,  the  entire  half 
of  the  tongue  must  be  removed  down  to  the  hyoid  bone  in  cases 
where  the  growth  is  situated  laterally,  the  entire  organ  when  situated 
centrally. 

As  can  be  seen  from  Plate  88,  the  growth  spreads  along  the 
lymph  spaces  in  the  hyo-glossus  and  genio-hyo-glossus  muscles,  in- 
ferior lingualis.  and  stylo-glossus,  and  therefore  every  fart  of  the 
affected  muscle  must  be  cleared  away  in  as  systematic  a  manner  as 
the  great  pectoral  is  removed  in  carcinoma  mammae. 

There  is  a  further  important  detail :  Cheatle's  specimens  show 
the  presence  of  glands  between  the  fibres  of  the  hyo-glossus,  and 
dissemination  of  cancer  cells  in  the  lymph  spaces  of  the  submucosa 
for  a  considerable  distance  away  from  the  primary  focus,  and  such 
evidence  proves  the  risk  of  partial  operations  in  any  but  very  early 
cases. 

In  cancer  of  the  tip  of  the  tongue  the  spread  of  the  disease,  as 
shown  in  the  diagram  of  the  lymphatics  (Plate  86),  is  through  the 
genio-hyoids,  and  these  muscles,  together  with  the  fascia  covering  them, 
must  be  removed. 

It  has  been  urged  that  in  all  cases  the  whole  tongue  should  be 
excised,  but  I  am  quite  unable  to  agree  with  this  suggestion.  As 
has-  been  shown,   the   tendency   of  the   growth    is   to  spread    along 


Fig.   1. — Section  of  tongue  showing  cancerous  growth  invading  the  genio-hyo-glossus. 


Fig.   2. — Section  of  tongue  showing  cancerous  growth   invading  the  hyo-glossus. 


PLATE  88. 


WHITEHEAD'S   OPERATION  219 

the  muscles  on    the    affected    Bide;    indeed,  the   septum    appet 
■   a  limiting  influence.     Recurrence  on  the  opposite  side  0 
tongue  La  very  rare,  and  the  more  extensive  operation  of  complete 
removal  should  be  reserved  for  those  cases  in  which  it  is  obvious  thai 
both  Bides  are  involved,  or  in  which  there  is  disease  of  the  opposite 
half  demanding  removal. 

Large  ulcerating  and  infiltrating  growths  will  require  complete 
removal,  and  so  will  most  of  the  growths  situated  in  the  posterior  part. 

THE    OPERATIONS    FOR  LINGUAL  CANCER 

1.  Whitehead's  intrabuccal  operation  and  its  modi- 
fications.- This  method  consists  in  removing  the  whole  or  half 
of  the  tongue  through  the  oral  cavity,  any  of  the  preliminary  steps 
mentioned  previously,  such  as  Laryngotomy  or  ligation  of  the  exter- 
nal carotid  or  lingual,  being  performed  according  to  the  opinion  of 
the  operator. 

In  cases  where  sufficient  room  cannot  be  obtained  by  the  intro- 
duction of  the  gag,  the  cheek  maybe  split  back  towards  the  masseter 
on  the  affected  side.  If  it  is  desired  to  follow-  out  the  recommendations 
given  above,  and  remove  the  muscular  tissue  down  to  the  hyoid  bone, 
this  additional  step  will  be  found  to  give  easy  access.  I  have  no 
hesitation  in  recommending  it,  as  we  must  no  longer  consider  the 
question  of  deformity,  but  endeavour  to  remove  the  disease  com- 
pletely. By  such  an  operation  as  this,  with  subsecpicnt  dissection 
of  the  glands,  the  requirements  of  the  early  case  are  met. 

Position  of  the  patient. — This  must  depend  upon  whether  a 
preliminary  laryngotomy  has  been  performed  or  not.  If  this  has 
been  done,  and  the  back  of  the  pharynx  has  been  firmly  plugged, 
the  position  of  the  patient  is  only  of  importance  to  the  operator  ;  the 
head  may  be  raised  or  turned  on  the  side,  whichever  appears  the  more 
convenient . 

"When  no  larpigotomy  has  been  done,  even  if  the  large  vessels 
have  been  tied,  there  is  always  a  risk  cf  blood  trickling  down  the 
larynx  into  the  lungs  and  favouring  the  development,  later,  of  septic 
pneumonia.  There  are  two  positions  in  which  the  patient  may  be 
placed  which  will  tend  to  prevent  this  : — 

i.  Rose's  position. — A  sandbag  is  placed  under  the  shoulders,  and 
the  head  is  allowed  to  hang  back  over  the  end  of  the  table  so  that 
the  mouth  and  throat  are  on  a  lower  level  than  the  trachea  ;  in  this 
position  little  blood,  even  when  the  bleeding  is  free,  can  pass  into 
the  lungs.  Unfortunately  the  position  causes  great  congestion  of  the 
veins  and  venous  bleeding. 

ii.  The  lateral  position. — The  patient  lies  on  his  side  with  the  head 
unsupported  by  a  pillow  and  turned  forwards  and  downwards  towards 


220  THE   TONGUE 

the  surgeon  ;  in  this  position  the  blood  tends  to  run  out  of  the  angle 
of  the  mouth.  Special  gags  which  do  not  interfere  with  this  position 
will  be  required. 

Gags. — The  surgeon  will  with  advantage  take  some  care  in  the 
selection  of  Ins  gags  for  these  eases.  Nothing  is  more  annoving,  even 
dangerous  occasionally,  than  the  slipping  of  the  gag  or  the  inability 
to  expose  the  parts  thoroughly.  Butlin  recommends  Coleman's  gag  ; 
Jacobson,  Hewitt's  modification  of  Mason's  gag.  Lane's  or  Wingrave  s 
is  a  useful  instrument  when  the  head  is  turned  on  the  side,  as  there 
are  no  handles  to  get  in  the  way.  A  pair  of  large  lip  and  cheek 
retractors  should  be  at  hand. 

When  only  half  the  tongue  is  to  be  removed,  the  gag  is  placed  on 
the  side  opposite  to  that  affected,  but  a  second  gag  is  often  required. 

Sponges. — Although  marine  sponges  have  been  abandoned  for 
modern  surgical  work  in  the  abdomen,  they  have  a  distinct  field  of 
usefulness  in  operations  on  the  mouth  and  throat,  and  are  strongly 
recommended.  It  will  be  found,  however,  that  the  coarse  Turkey 
sponge  is  much  more  serviceable  than  the  finer  sponges  usually 
employed,  as  it  absorbs  blood  better  and  does  not  get  so  slimy.  One 
dozen  small  swabs,  to  be  used  on  holders,  and  three  or  four  larger  ones, 
each  firmly  secured  by  a  stout  silk  thread,  should  be  in  readiness. 
These  are  wrung  out  of  weak  carbolic  (1-100),  and  are  placed  in 
charge  of  a  nurse,  who  rinses  and  returns  them  clean  to  the  surgeon 
as  he  requires  them. 

The  anaesthetic. — When  anaesthesia  has  been  induced,  the 
administration  may  be  continued  either  through  the  laryngotomy 
tube  or  the  nose,  as  the  case  may  be.  Chloroform  is  the  best 
anaesthetic.  The  laryngeal  reflex  should  not  be  lost.  Intubation 
anaesthesia  is  largely  employed  in  America. 

Operation. — The  mouth  being  widely  opened,  two  stout  threads 
are  passed  through  the  tip  of  the  tongue,  one  on  each  side  of  the 
middle  line.  A  further  thread  may  with  advantage  be  j 
through  the  base  of  the  organ  close  to  the  epiglottis,  of  course 
wide  of  the  disease.  This  step  is  especially  advantageous  when 
the  whole  tongue  is  to  be  removed,  and  is  usually  required  at  the 
completion  of  the  operation,  to  prevent  the  stump  falling  back  and 
occluding  the  larynx ;  as  a  preliminary  measure  it  will  facilitate 
the  protrusion  of  the  tongue  and  also  the  dragging  of  the  bleeding- 
point  into  view  in  the  event  of  haemorrhage. 

The  tongue  is  now  pulled  well  forwards  by  means  of  the  bgatures, 
and  the  surgeon  cuts  through  the  tongue  along  the  middle  line  of 
the  dorsum  from  base  to  tip  by  means  of  a  knife  (Fig.  339).  This 
in<  ision  is  deepened,  by  cutting,  blunt  dissection,  or  tearing,  to  the 
hyoid  bone.     The  mucous  membrane  is  then  cut  through  with  scissors, 


WHITEHEAD'S   OPERATU  >\  221 

around  the  affected  half,  from  the  Ersenum  anteriorly,  to  the  anterioi 
pillar  of  the  fauces  posteriorly.     U  accessary,  this  Latter  structure  i 
divided.     As  much  mucous  membrane  as  possible  should  be  Left,  at 
it  falls  into  position  and  covers  the  nn\  surfaces,  bul  the  ELrsI  i 
tial  is  to  cut  wide  of  i  he  gro^  t  h. 

If  the  disease  is  situated  near  the  anterior  pari  of  the  tongue,  il 
is  advisable  to  draw  one  or  two  incisors,  so  thai  the  scissors  can  be 
dipped  down  behind  the  jaw  close  to  the  bone. 

The  affected  half  is  now  free  internally  and  laterally,  so  thai    by 


Fig.  339. — Whitehead's   operation  (intrabuccal)  for  removal 
of  half  the  tongue.     {After  Fowler.) 


traction  on  the  suture  it  can  be  dragged  well  out  of  the  mouth.  By 
a  series  of  short  scissor-cuts,  beginning  in  front,  the  deep  attachments 
to  the  hyoid  bone  are  severed  ;  this  dissection  should  be  very  thorough, 
every  effort  being  made  to  remove  the  muscular  fibres  right  down  to 
the  hyoid.  The  half  of  the  tongue  will  now  be  attached  posteriorly 
only,  and  contains  the  lingual  arteries  still  intact.  If  these  have  not 
been  secured  previously,  they  may  be  exposed  before  division,  as 
follows  :  A  number  of  short  snips  are  made  through  the  posterior 
attachments  of  the  organ,  with  separation  of  the  muscular  fibres  : 
near  the  middle  line  the  artery  will  start  into  view  as  a  bluish  cord, 


222  THE   TONGUE 

and  can  then  be  secured  with  forceps  or,  better,  ligatured  by  means  of 
an  aneurvsni-ncedle,  before  the  final  severance  of  the  affected  portion. 
It  is  well  worth  while  to  spend  a  little  time  securing  the  vessel,  for  the 
lingual  tissue  is  extremely  friable,  and  as  the  tongue  is  brought  forward 
under  tension  the  forceps  may  be  dragged  off  and  troublesome  bleeding 
may  ensue  ;  if  this  does  occur,  the  fingers  should  be  passed  back 
beyond  the  epiglottis  and  the  base  of  the  tongue  should  be  hooked 
forward,  after  the  method  recommended  by  Heath — a  step  which, 
while  it  checks  the  bleeding,  temporarily  enables  the  stump  to  be 
brought  well  into  view. 

Cathcart  (quoted  by  Jacobson)  secures  the  artery  in  the  following 
way  :  After  the  ordinary  steps  have  been  taken  and  the  tongue,  well 
freed,  has  been  dragged  out  of  the  mouth,  "  the  anterior  border  of 
the  hyo-glossus  is  defined  by  a  few  vertical  strokes  of  the  director  ; 
this  instrument  is  next  insinuated  beneath  the  muscle,  the  tissues 
being  separated  with  the  point  before  it  is  pushed  in.  The  muscle  is 
next  carefully  cut  through  on  the  director  for  about  two-thirds  of 
its  extent  (this  incision  should  be  close  to  the  hyoid),  and  the  fibres 
retracting  leave  the  artery  exposed  at  the  bottom  of  the  wound,  covered 
only  with  a  little  connective  tissue  ;  it  can  be  under-run  with  a  ligature 
carried  by  an  aneurvsm-needle  and  leisurely  tied."  Whitehead  relied 
mainly  on  twisting  the  artery,  but  it  is  wiser  to  ligature  it  with  silk 
or  chromicized  catgut. 

If  the  whole  tongue  is  to  be  removed,  it  may  be  split,  provided 
that  the  split  does  not  pass  through  diseased  tissue,  and  each  half 
may  be  dealt  with  as  recommended  above;  or  each  side  may  be  freed 
without  the  median  incision,  and  the  arteries  secured  by  the  methods 
previously  recommended.  In  any  case  when  the  whole  organ  is  ex- 
cised a  stout  ligature  should  be  left  through  the  stump  close  to 
the  epiglottis  to  enable  the  surgeon  to  pull  it  forward  in  case  of 
haemorrhage,  and  also  to  prevent  the  falling  back  of  the  stump  and 
consequent  obstruction  to  respiration. 

After  the  diseased  tissues  have  been  freely  removed,  any  vessels 
which  still  bleed  should  be  clamped,  and  tied  if  possible,  but  the 
friable  tissue  and  the  depth  of  the  wound  may  make  this  procedure 
difficult.  Any  mucous  membrane  that  is  left  should  be  used  to  cover 
over  the  raw  surface,  being  fixed  in  position  by  catgut  sutures  ;  if 
only  half  the  tongue  has  been  excised,  the  anterior  part  may  be  folded 
back  and  used  to  cover  the  raw  surface  near  the  median  line.  Such 
a  step  checks  the  oozing  and  accelerates  the  healing  of  the  wound. 

If,  in  spite  of  the  above  precautions,  bleeding  still  continues, 
gauze  strips  should  be  packed  on  to  the  raw  surface. 

Whitehead  swabs  the  wound  over  with  a  special  varnish,  made  by 
substituting  for  the  spirit  used  in  Friar's  balsam  a  saturated  solution 


KOGHER'S   SI  fBMAXILL .\m     OPERATION 


!23 


oi  iodoform  in  turpentine  or  ether,     Iodoform  powder  may  I" 
instead.     I  recommend  the  use  oi  antiseptics,  especially  <»f  iodoform 
and  carbolic,  Eoi  t  bese  cases. 

The  gag  is  removed,  and  the  suture  through  the  lingual   be 
fixed  to  the  cheek  by  a  piece  oi  strapping. 

The  after-treatment   will  be  considered  later. 

_'.  Kochers  submaxillary  method.  -  I i\  this  method, 
which  was  introduced  by  Professor  Kocher  in  1880,  an  attempl  was 
made  to  remove  the  lymphatic  glands,  Balivary  glands,  and  tongue  in 


Fig.  3-40. — Lines  of  incision  for  modified  Kocher  s  operation. 


continuity,  without  cutting  across  infected  lymphatic  spaces  ;  further, 
a  preliminary  tracheotomy  was  performed,  and  the  pharynx  was  kept 
plugged  for  some  days  until  all  danger  of  septic  pneumonia  was  past. 
Although  founded  on  a  sound  scientific  basis,  the  method  has  not 
been  very  successful,  and  Kocher  himself  has  abandoned  it  for  the 
procedure  usually  described  as  Syme's  operation  (p.  225). 

Cheatle's  modification. — Lenthal  Cheatle  has  described  to  mo 
an  operation  which  is  a  modification  of  Kocher's  method,  and  which 
is  believed  to  be  an  advance  on  many  of  the  operations  practised. 


224  THE   TONGUE 

No  preliminary  tracheotomy  or  laryngotomy  is  done.  A  free 
incision  is  made  from  the  mastoid  process  to  the  symphysis,  curving 
down  below  the  hyoid,  and  a  vertical  or  oblique  incision  is  added 
below  (Fig.  340).  The  dissection  is  then  carried  out  from  below 
upwards,  all  glands,  fat,  and  fascia  being  dissected  away  from  the  main 
vessels.  The  facial  and  lingual  arteries  are  tied  near  their  origin: 
The  interval  between  the  posterior  belly  of  the  digastric  and  the  mylo- 
hyoid is  now  sought  for,  and  these  muscles  are  retracted,  the  former 
backwards  and  downwards,  and  the  latter  forwards,  its  fibres  being 
divided  if  necessary.  The  base  of  the  tongue  at  its  attachment  to 
the  hyoid  is  exposed,  and  the  hyo-glossus  is  divided  along  its  whole 
hyoid  attachment  close  to  the  bone  ;  continuing  anteriorly,  the  genio- 
hyo-glossus  is  cut  close  to  the  jaw — a  difficult  step — and  the  median 
interval  between  the  muscles  is  sought  for.  The  genio-hyoid  fibres 
of  the  genio-hyo-glossus  are  very  rarely  invaded  and  may  be  left. 
If  only  one  half  is  to  be  removed,  the  mouth  is  now  gagged  open  as  in 
Whitehead's  method,  and  the  remaining  attachments  of  the  organ 
are  divided  as  in  that  operation,  the  posterior  division  going  back 
to  the  styloid  process.  Turning  again  to  the  neck,  it  will  now  be 
possible  to  remove  the  tongue  and  the  other  structures  freed  by  dis- 
section in  continuity,  the  separation  being  effected  by  a  few  touches 
of  the  knife.     The  wound  is  left  widely  open. 

If  the  whole  organ  is  to  be  removed,  similar  steps  are  taken  on 
the  opposite  sides  to  free  the  deep  attachments  and  to  secure  the 
main  vessels  ;  the  oral  mucous  membrane  is  divided  by  the  intra - 
buccal  method,  and  the  whole  mass  is  extracted  from  the  side  first 
attacked. 

Author's  modification. — I  have  recently  practised  a  modifica- 
tion of  this  operation  for  cases  of  cancer  limited  to  one  half  of 
the  tongue,  with  satisfactory  results.  The  main  points  of  difference 
are  these  : — 

i.  The  three  flaps  fashioned  by  the  skin  incisions  are  turned 
upwards,  backwards,  and  forwards,  and  consist  of  skin  only,  very 
little  subcutaneous  fat  being  left. 

ii.  The  external  carotid  is  ligatured  as  well  as  the  lingual  and 
facial  arteries  in  the  course  of  the  dissection. 

hi.  The  dissection  is  carried  right  on  to  the  face,  above  the  lower 
border  of  the  mandible,  so  that  the  glands  in  the  parotid  and  mas- 
seteric regions  are  removed. 

iv.  Everything  except  the  main  vessels  and  muscles  is  removed 
within  the  triangular  area  bounded  by  these  flaps. 

v.  The  attachment  of  the  tongue  to  the  hyoid  bone  is  cut  through. 

vi.  Before  the  final  step  of  removing  the  tongue  is  attempted,  the 
sterno-mastoid  is  stitched  to  the  digastric  and  the  hyoid  muscles, 


MODIFIED    ROCHER'S   OPERATION 

a  to  cover  up  the  carotid  and  jugular  win,  and  the  skin  wound 

i.--    partially   closed. 

vii.  Half  the  tongue  is  excised  from  the  mouth  alter  White- 
head's method,  the  division  <>f  the  muscles  previously  mentioned 
making  it  an  easy  matter  to  complete  a  free  removal.  There  is  no 
bleeding. 

viii.  1  make  it  a  point  that  the  mouth  and  neck  wounds  should 
freely  communicate  with  one  another,  so  that  I  feel  more  certain 
that  no  "intervening"  tissue  has  been  left  behind.  The  wound  is 
packed  with  iodoform  gauze. 

ix.  Enlarged  glands  on  the  opposite  side  are  removed  at  a  second 
operation. 

I  am  quite  satisfied  with  the  procedure  in  cases  where  only  half  the 
tongue  has  to  be  excised.  It  seems  sound  and  adequate;  the] 
no  trouble  with  the  wound  in  the  neck,  if  sufficient  care  has  been 
exercised  in  cleaning  the  mouth  beforehand  ;  and  I  have  not  found 
that  it  puts  the  recuperative  power  of  patients  to  any  severe  test. 
On  the  other  hand,  if  both  sides  of  the  neck  have  to  be  attacked  in 
more  advanced  cases,  and  the  whole  tongue  has  to  be  excised,  the 
risk  is  very  much  greater  ;  but,  in  my  opinion,  it  remains  the  best 
procedure  for  dealing  with  carcinoma  of  the  tongue. 

Whether  the  mortality  which  follows  its  employment  will  be  so 
high  as  to  render  it  unjustifiable  remains  as  yet  to  be  seen.  Cheatle 
lays  considerable  stress  on  leaving  the  wounds  widely  open  so  that 
free  drainage  is  obtained.  He  does  not  dissect  the  glands  below  the 
omo-hyoid  at  the  time  of  the  main  operation,  but  defers  that  step, 
if  required,  until  a  later  date. 

The  great  dangers  of  the  operation,  apart  from  septic  pneumonia, 
are  sloughing,  cellulitis,  and  secondary  haemorrhage ;  but  covering 
the  wound  surface  with  sterile  vaseline,  as  suggested  by  Upcott  cf 
Hull  for  operations  on  the  tonsil,  might  possibly  be  of  service  in 
preventing  cellular  infection.  I  have  been  very  pleasantly  surprised 
to  find  how  kindly  these  neck  wounds  heal,  but  I  spend  seven  or 
eight  days  in  preliminary  cleaning  of  the  mouth. 

3.  Syme's  operation. — This  operation  is  practically  identical 
with  that  now  performed  by  Professor  Kocher.  It  consists  essentially 
in  dividing  the  soft  tissues  in  the  middle  line  from  the  lip  to  the 
hyoid  bone,  and  sawing  through  the  mandible  so  as  to  gain  acces- 
the  mouth  and  hyoid  regions.  Kocher  operates  with  the  patient 
in  the  Trendelenburg  position,  but  the  operation  can  be  efficiently 
performed  if  the  head  and  shoulders  are  raised  and  held  forwards 
as  in  operations  upon  the  tonsils  and  throat. 

If  it  be  desired,  lateral  incisions  may  be  carried  outwards  from 
the    lower   termination  of    the   vertical    incisions,   and   flaps   can   be 

P 


226  THE   TONGUE 

dissected  up,  thus  enabling  the  operator  to  remove  the  salivary  and 
lymph-glands  of  the  submaxillary  triangle  at  the  same  time. 

The  actual  operation  is  performed  as  follows  :  The  ansesthetie 
having  been  administered  (a  preliminary  laryngotomy  or  tracheotomy 
is  not  required),  the  surgeon  divides  the  soft  parts  of  the  chin  as  far 
down  as  the  hyoid  bone.  The  vessels  being  secured,  the  jaw  is  drilled, 
without  previous  separation  of  the  periosteum,  below  the  teeth  a 
quarter  of  an  inch  on  either  side  of  the  middle  line,  and  is  then 
sawn  through.  The  two  halves  are  forcibly  retracted,  the  tongue 
is  well  drawn  out  by  a  loop  of  strong  silk,  the  mucous  membrane 
snipped  through  between  the  tongue  and  the  alveolar 'process,  and 
the  anterior  pillars  of  the  fauces  are  divided.  The  genio-hyo-glossi 
and  genio-hyoids  (one  side  only  if  only  half  the  tongue  is  to  be 
removed)  are  now  cut  through,  and  the  tissues  of  the  floor  of  the 
mouth  separated  as  deeply  as  necessary  with  scissors  or  bistoury 
aided  by  the  finger,  any  vessels  that  require  it  being  tied  with  silk. 
The  tongue  being  thus  freed  laterally  and  below  as  far  back  as  is 
needful,  the  transverse  section  is  made  one  half  at  a  time,  the  lingual 
arteries  being  secured  as  recommended  above. 

Bleeding  is  checked,  the  wound  is  treated  by  Whitehead's  method, 
and  the  two  halves  of  the  jaw  are  united  by  wire ;  the  skin  incision 
is  sewn  up,  but  a  large  drain  is  inserted  into  its  lower  end  above 
the  hyoid  bone. 

There  is  no  doubt  that  this  operation  gives  an  easy  access  to  the 
diseased  organ,  and  it  is  especially  valuable  when  the  growth  extends 
far  back.  At  the  same  time,  it  is  open  to  the  objections  that  the 
lymphatic  glands  are  not  thoroughly  removed,  that  there  is  some 
risk  of  cancer  contamination  of  the  wound,  and  that  the  jaw  is 
liable  to  necrose  near  the  saw-cut.  In  cases  where  the  disease  lies 
anteriorly  and  extends  to  the  bone,  the  surgeon  can  by  a  simple 
modification  remove  growth  and  bone  in  continuity. 

Regnoli's  operation,  which  consists  in  an  exposure  of  the  tongue 
by  a  transverse  incision  below  the  jaw,  with  transverse  division  of  the 
muscles  attached  to  the  hyoid,  is  rarely  practised.  It  is  most  suitable 
in  cases  where  the  disease  attacks  the  anterior  part  of  the  tongue 
and  floor  of  the  mouth. 

Carless,  quoted  by  Jacobson,  recommends  transhyoid  pharyng- 
otomy  when  the  disease  is  far  back,  the  anterior  part  of  the  tongue 
being  saved. 

When  the  growth  affects  the  posterior  part  of  the  tongue  or  spreads 
back  to  the  palate  and  tonsil  a  favourable  result  can  be  obtained  but 
rarely,  and  very  complicated  and  dangerous  procedures,  such  as 
Langenbeck's  method  of  slitting  the  cheek  and  dividing  the  jaw,  will 
be  required  if  complete  extirpation  is  to  be  attempted.     The  results 


OPERATIONS    FOR    I  [NGUAL   CARCINOMA      217 

of  those  operations  rarely  justify  their  performance,  and  it  musl 
be  admitted  that  earner  of  the  tongue  far  back  is  most  unfavourable 
for  surgical  treatment. 

When  the  jaw  is  involved  anteriorly,  the  outlook,  though  Less 
hopeless,  is  distinctly  unfavourable.  An  attempl  Bhould  lie  made  to 
remove  the  growth  and  the  affected  bone  by  some  of  the  methods 
mentioned  above ;  and  it  is  often  possible  to  leave  a  bridge  of  healthy 
bone  from  the  lower  border  of  the  horizontal  ramus,  with  the  effect 
of  contributing  to  the  patient's  comfort. 

Whatever  operation  is  performed,  it  is  always  advisable  to  pass  a 
suture  through  the  stump  of  the  tongue,  and  to  bring  the  suture 
out  of  the  mouth  and  fasten  it  to  the  cheek  or  ear. 

After-treatment  in  operations  for  lingual  cancer. — 
For  the  first  twenty-four  hours,  or  longer  in  severe  cases,  the 
patient  must  be  kept  lying  on  the  side  or  even  on  the  face,  with 
the  head  low,  so  that  the  discharges  can  trickle  out  of  the  mouth 
on  to  a  pad  of  gauze  or  wool.  A  special  nurse  should  always  be 
in  attendance,  and  should  watch  for  bleeding  (usually  venous  oozing) 
and  for  obstruction  to  respiration.  Bleeding  as  a  complication  will 
be  considered  later. 

If  the  breathing  becomes  obstructed,  the  stump  of  the  tongue 
should  be  pulled  forwards  by  means  of  the  attached  string ;  and  if 
that  fails,  a  finger  should  be  passed  to  the  base  of  the  tongue,  the 
pharynx  cleaned,  and  the  stump  hooked  forwards.  These  manoeuvres 
usually  succeed.  Morphia,  |—|  gr.,  should  be  given,  and  the  patient 
should  be  fed  by  nutrient  enemata  and  disturbed  as  little  as 
possible. 

If  the  weather  is  cold,  screens  or  curtains  should  be  placed  round 
the  bed,  and  a  bronchitis  kettle  charged  with  some  antiseptic,  such 
as  tinct.  benz.  co.  or  guaiacol  carbonate,  should  be  used  to  keep  the 
air  warm  and  moist.  This  is  not  intended  to  imply  that  every  patient 
is  to  be  kept  in  an  atmosphere  saturated  with  steam,  but  to  suggest 
that  there  are  very  definite  uses  still  for  the  steam-kettle.  If  the 
steaming  is  overdone  there  is  a  greater  risk  of  pneumonia.  Should 
the  patient  show  signs  of  collapse  after  the  operation,  enemata  of 
hot  saline  (103°  F.)  with  strong  coffee  and  brandy  should  be  given. 

During  the  first  twenty-four  hours  the  patient  should  not  be  dis- 
turbed ;  the  mouth  may  be  swabbed  out  occasionally  with  some  weak 
permanganate  of  potash  if  there  is  any  tendency  to  the  collection  of 
clots  and  mucus  ;  but  on  the  whole  the  quieter  he  is  left  the  better, 
for  frequent  and  unnecessary  manipulations  are  decidedly  harmful. 

Small  pieces  of  ice  may  be  given  to  him  if  the  mouth  is  dry  and 
thirst  is  intense. 

At   the   end   of   the  twenty-four  hours   any  gauze   plugging   that 


228  THE   TONGUE 

has  been  introduced  should  be  removed,  and  the  routine  treatment 
of  the  mouth  undertaken.  This  consists  in  frequent  irrigations  and 
swabbings  with  weak  antiseptics,  preferably  weak  carbolic  or  per- 
manganate of  potash,  alternated  with  a  solution  of  bicarbonate  of 
soda  to  get  rid  of  the  clinging  mucus.  A  large  irrigator  fixed  to 
the  wall  near  the  head  of  the  bed,  and  fitted  with  a  glass  vaginal 
douche  nozzle  controlled  by  a  tap  or  clip,  allows  the  nurse,  and 
afterwards  the  patient,  to  wash  out  the  oral  cavity  very  thoroughly  ; 
of  course,  provision  must  be  made  for  free  exit  of  the  fluid. 

The  patient  should  be  propped  up  in  the  sitting  position  for 
dressing  and  inspection  of  the  mouth,  which  should  be  done  in  a  good 
light,  and  in  the  less  severe  cases  he  may  remain  sitting  up  after  the 
first  twenty-four  hours  ;  in  the  more  severe  the  recumbent  posture 
must  be  maintained  for  two  or  more  days. 

Dawbarn  insists  on  the  need  for  keeping  these  patients  in  the 
Trendelenburg  position  until  they  are  able  to  swallow,  so  preventing 
them  from  inhaling  septic  matter  from  the  wound.  This  position 
is  very  uncomfortable  for  the  patient,  and,  if  the  wound  can  be  kept 
decently  clean,  is  unnecessary  ;  but  if  the  wound  is  foul,  owing  to 
the  loss  of  control  of  the  epiglottis  there  is  a  real  danger  of  septic 
particles  finding  their  way  down  the  larynx  and  trachea,  and  the 
position  must  be  maintained. 

Every  two  hours  during  the  day,  and  every  four  during  the  night, 
the  nurse  on  duty  should  gently  wipe  away  blood  and  debris  with  a 
small,  soft  sponge  moistened  in  antiseptic.  The  patient  should  be 
encouraged  to  irrigate  his  own  mouth  every  hour  during  the  day. 
Adherent  blood-clot  can  be  removed  with  forceps,  but  when  sloughs 
appear  the  greatest  care  should  be  exercised  in  detaching  them,  as 
their  removal  may  be  followed  by  haemorrhage.  If  the  case  goes 
well  the  patient  should  be  got  up  in  a  chair  on  the  third  day.  It 
will  often  be  advisable  to  keep  the  patient  recumbent  for  a  longer 
period,  and  to  delay  his  getting  up  if  old  and  enfeebled,  but  the 
special  points  to  attend  to  are  frequent  irrigations  and  the  pre- 
servation of  local  cleanliness  as  far  as  it  is  possible  to  obtain  it. 

Feeding. — For  the  first  twenty -four  or  forty-eight  hours,  food 
should  be  given  rectally  ;  after  that,  in  many  cases  the  patient  is 
able  to  swallow,  and  the  food  is  given  by  a  feeder,  to  the  spout  of 
which  is  attached  a  rubber  tube  that  can  be  passed  well  to  the  back 
of  the  throat.  It  is  well  to  make  a  trial  with  some  water  first,  in 
case  the  food  should  regurgitate  and  soil  the  wound. 

All  food  given  should  be  carefully  sterilized  until  healthy  granu- 
lations have  covered  the  raw  surface. 

In  the  more  severe  cases  the  patient  must  be  fed  through  nasal 
or  oesophageal  tubes  until  the  power  of  swallowing  is  regained.     Great 


OPERATIONS    FOR    LINGUAL   CARCINOMA 

■  should   be  exercised   in   the   feeding,  and   absolute  cleanlinec 
essential. 

Complications. — Haemorrhage  may  occur  shortly  after  the 
patienl  has  been  returned  to  bed,  and  is  commoner  after  the  more 
Bevere  operations.  It  may  be  due  to  the  slipping  of  a  ligature,  or  to 
the  opening  up  of  veins  which  had  ceased  to  bleed  during  t  he  operation. 
Such  a  complication  must  be  carefully  watched  for,  since  ;i  sudden 
haemorrhage  of  this  kind  may  choke  the  patient,  or  by  trickling  down 
the  trachea  favour  the  development  of  septic  pneumonia.  It  the 
bleeding  is  free,  the  mouth  should  be  widely  opened,  clots  swabbed 
out  with  a  sponge,  and  a  strip  of  gauze  packed  on  to  the  bleeding 
area.  If  thought  advisable,  forceps  may  be  applied  and  the  vessel 
ligated. 

True  secondary  hemorrhage  is  rare,  in  spite  of  the  often  septic 
state  of  the  wound  ;  even  when  extensive  operations  are  done  upon 
the  neck,  which  is  thrown  into  communication  with  the  mouth,  it 
is  rare  for  the  ligated  vessels  to  bleed.  The  precaution  should 
always  be  taken,  in  these  cases,  to  tie  the  vessels  a  little  distance, 
from  half  an  inch  to  an  inch,  away  from  the  main  trunk  ;  if  the 
external  carotid  is  tied,  it  should  not  be  secured  too  close  to  the 
common  vessel. 

Should  this  secondary  bleeding  occur,  it  is  usually  encountered 
when  the  sloughs  separate,  is  rarely  serious,  and  readily  yields  to 
treatment.  The  mouth  should  be  opened  widely,  washed  out  and 
swabbed  ;  if  the  bleeding-point  can  be  seen,  it  should  be  caught  with 
forceps  and  a  ligature  applied.  Failing  this,  it  is  often  sufficient  to 
pack  a  strip  of  gauze  firmly  down  towards  the  bleeding-spot  and  get 
the  patient  to  close  his  mouth  upon  it.  As  a  temporary,  even  as  a 
permanent,  measure  this  is  wonderfully  efficient  ;  in  the  only  case 
of  secondary  haemorrhage  under  my  care,  this  method  of  treat- 
ment was  followed  by  the  complete  arrest  of  the  bleeding. 

Sloughing  and  cellulitis. — After  extensive  operations,  especially 
where  the  mouth  has  been  unusually  septic  beforehand,  cellulitis  may 
occur.  It  should  be  treated  by  free  incisions  and  carbolic  fomenta- 
tions. As  a  preventive  measure,  few  sutures  should  be  employed  in 
the  large  neck  wounds,  as  they  favour  the  retention  of  discharges. 
Frequent  irrigations  are  the  surest  way  of  dealing  with  these  infected 
wounds.  I  have  no  experience  of  antistreptococcic  serum,  but  recom- 
mend the  preparation  and  use  of  a  vaccine. 

This  complication,  following  on  a  long  and  exhausting  operation, 
is  a  very  serious  one,  likely  to  lead  to  a  fatal  issue. 

Septic  pneumonia  is  responsible  for  the  fatal  termination  of  a 
lame  number  of  cases.  More  can  be  done  to  prevent  it  than  to 
treat  it  when   it  has  supervened.       Local    cleanliness,    avoidance   of 


230 


THE   TONGUE 


hemorrhage,  and  the  adoption  of  a  position  of  the  patient  favouring 
the  free  removal  of  discharges  are  to  be  strongly  advocated.  In 
very  septic  states,  inhalations  of  guaiacol  carbonate  are  of  distinct 
value. 

When  signs  of  pneumonia  have  developed,  every  effort  should  be 
made  to  support  the  patient's  strength  with  nourishing  food  and 
stimulants.  A  localized  abscess  or  gangrene  of  the  lung  will  probably 
require  treatment,  should  the  patient  survive. 

Removal    of    the    glands. — If    the  intrabuccal  method    of 


Fig.  341. — Incisions  for  Butlin's  gland  dissection. 


Whitehead  is  selected,  whether  the  glands  appear  enlarged  or  not,  a 
complete  dissection  should  be  made  of  the  anterior  triangle  of  the 
neck  within  ten  days  of  the  removal  of  the  tongue.  The  indications 
for  attacking  both  sides  have  been  given  already. 

Butlin's  method  (Fig.  341). — The  best  method  for  removing 
the  glands  in  early  cases  is  that  described  by  Butlin.  Three 
flaps  of  skin,  with  very  little  subcutaneous  fat,  are  dissected  back, 
and  then,  starting  from  below  upwards,  everything  is  cleaned 
away  in   one  sheet   except   the    muscles  and  the  large  vessels.     The 


LINGUAL   CARCINOMA:  GLAND    DISSECTION    231 

submaxillary  gland  and  the  lower  portion  oi  the  parotid  gland 
should  be  removed  deliberately.  This  point  is  especially  important, 
as  there  are  a  number  oi  Lymphatic  glands  Bituated  among  the 
glandular  alveoli  in  both  instances.  The  wound  should  be  freely 
drained.  Healing  is,  as  a  rule,  by  6rs1  intention,  and  the  results 
arc  excellent  ;  some  saliva  may  escape  from  the  posterior  angle  oi  the 
wound,  but  t  his  soon  ceases  to  run.  1  use  two  drains.  The  operator 
should  bear  in  mind  that  the  Lymph-vessels  from  the  tip  of  the  tongue 
pass  directly  to  the  glands  of  the  internal  jugular  vein. 

Maitland's  operation  is  somewhat  more  radical,  and  is  suited 
to  more  advanced  cases.  The  skin  incisions  are  similar,  except  that 
the  lower  vertical  incision  is  carried  back  along  the  clavicle.  Ma  it  land 
is  careful  not  to  leave  the  subcutaneous  fat  behind  in  the  submental 
and  submaxillary  regions,  as  the  glands  here  are  very  superficial.  He 
begins  his  dissection  posteriorly  and  above  after  reflection  of  his  flaps, 
and  insists  on  the  removal  of  the  lower  part  of  the  parotid  and  the 
whole  of  the  submaxillary  gland.  Next  lie  dissects  the  anterior  triangle 
from  below,  dividing  the  sterno-mastoid,  and  then,  working  upwards, 
he  approaches  the  region  already  attacked,  finally  severing  the  sterno- 
mastoid  at  its  upper  attachment.  If  necessary,  he  removes  the 
internal  jugular  vein  subsequently  ;  he  does  not  recommend  secur 
ing  it  before,  as  the  veins  become  congested,  and  there  is  then  a 
great  deal  of  venous  oozing.  This  is  a  very  radical  operation,  and 
efficient  ;  it  gives  easy  access  to  the  upper  deep  cervical  glands,  which 
are  reached  with  difficulty  when  the  sterno-mastoid  is  preserved, 
and  it  is  not  open  to  the  same  objection  as  Crile's  dissection,  which 
entails  temporary  compression  of  the  common  carotid. 

Block  dissection,  as  practised  by  Crile,  should  be  reserved  for 
the  most  advanced  cases.  It  is  an  operation  of  the  greatest 
magnitude,  and  consists  in  removing  the  glands,  the  sterno-mastoid, 
and  the  internal  jugular  vein  in  one  solid  mass  from  below  upwards. 
A  clamp  is  placed  on  the  common  carotid  artery.  The  main  skin 
incisions  are  similar  to  those  employed  by  Butlin. 

Cases  so  advanced  as  to  reqiure  these  extremely  radical  measures 
are  regarded  by  most  surgeons  as  inoperable. 

General  conclusions  with  regard  to  operations  for 
lingual  cancer. — 1.  For  very  early  cases  the  removal 
of  the  tongue  by  Whitehead's  method,  and  dissection  of 
the  glands  in  ten  days'  time,  may  be  adequate,  but  it  is 
inferior  to  Butlin's. 
2.  For  more  advanced  cases,  with  definite  enlargement  of  the 
glands,  Cheatle's  modification  of  Kocher's  operation  is  to  be 
preferred.  On  the  whole,  I  recommend  this  as  the  routine 
operation  for  all  cases  that  permit  of  its  being  done. 


232  THE   TONGUE 

3.  If  in  these  advanced  cases  a  two-stage  operation  is  decided  upon, 
the  glands  should  be  attacked  first,  the  external  carotid  or 
its  branches  should  be  tied,  and  the  tongue  should  be  excised 
later. 

L  In  all  advanced  cases,  and  in  those  specially  mentioned  above, 
the  glands  on  the  side  opposite  to  the  disease  should  be  removed 
subsequently. 

Results.  Mortality.— Whitehead  reports  101  cases  with  only  3 
operative  deaths.  Butlin  gives  two  tables,  11  out  of  98  in  the  first 
series,  9  out  of  99  in  the  second  ;  the  mortality  in  the  second  series 
would  be  lower  but  for  the  severe  procedures  practised  in  advanced 
cases.  Recurrence  has  been  the  rule,  the  successful  cases  being  28 
in  the  first  series,  32  in  the  second.  These  are  better  figures  than  most 
surgeons  can  quote.  If  our  results  are  to  improve,  we  must  operate 
early,  and  even  more  extensively  than  has  been  the  custom  in  the  past. 

Some  of  the  procedures  described  are  still  in  the  experimental 
stage,  and  very  careful  observations  will  be  required  to  decide  whether 
the  simpler  and  less  dangerous  method  of  Whitehead  is  to  be  pre- 
ferred, in  spite  of  its  incompleteness,  or  whether,  by  improvements  in 
operative  technique,  we  can  so  lower  the  mortality  of  the  extensive  and 
scientific  modern  operations  as  to  make  them  more  generally  applicable. 

Palliative  treatment. — For  the  unfortunate  patients  who 
seek  surgical  advice  when  the  growth  has  extended  too  far  for  radical 
treatment,  little  can  be  done  beyond  an  attempt  to  relieve  the  more 
distressing  symptoms — pain,  salivation,  and  fetor.  How  far  a  surgeon 
is  justified  in  removing  a  f ungating  cancer  merely  for  the  relief  of  the 
local  condition  must  be  left  to  his  discretion,  and  the  prospects  of 
the  case  must  be  clearly  explained  to  the  patient. 

Pain  can  be  mitigated  by  local  applications  of  cocaine  and  mor- 
phia, and  the  lingual  nerve  may  be  divided— a  measure  which  is  said  to 
check  the  salivation.     Ligature  of  the  lingual  arteries  has  little  effect. 

For  the  fetor  no  application  is  better  than  iodoform,  but  the  odour 
of  this  drug  is  so  disagreeable  to  some  patients  that  carbolic  acid,  per- 
oxide, thymol,  or  creosote  may  be  used  instead.  Atropin,  .>llHI--11(lgr., 
combined  with  morphia,  may  be  given  liberally  to  ease  the  final  stages 
of  one  of  the  most  distressing  diseases  to  which  man  is  subject. 

Radium  treatment. — The  emanations  of  radium  contain  cer- 
tain rays,  a,  /3,  7,  which  have  a  powerful  action  on  the  tissues  of 
the  body,  the  7  rays  being  very  potent  in  restraining  cell-activity, 
and  so  are  of  value  in  the  treatment  of  cancer,  nsevi,  etc.  Radium 
should  never  be  employed  by  anyone  unfamiliar  with  its  application 
and  effects,  but  in  suitable  cases  it  is  of  decided  assistance  to  the 
surgeon. 

As  in    the    case    of   nsevi    elsewhere,    its    action   is   prompt  and 


LINGUAL   CARCINOMA:    RADIUM    TREATMEN1 

remarkable  in  bringing  about  a  complete  destruction  <>f  the  nrovoid 

t  issue. 

In  cancel-  it  should  never  be  regarded  as  an  alternative  bo  opera- 
tion if  operation  is  feasible,  but  by  its  use  an  unfavourable  growth 
will  often  improve  so  thai  an  operation  may  be  attempted ;  while, 
after  an  operation  has  been  performed  successfully,  I  am  firmly  of 
the  opinion  that  the  application  of  radium  has  some  efiect  in  pre- 
venting recurrence. 

Radium  may  ease  the  pain  in  inoperable  eases,  but  its  curative 
effects  on  the  cancer  cell  are  much  less  marked  in  lingual  cancer  than 
in  cancer  situated  elsewhere. 

BIBLIOGRAPHY 
Burton,  Lancet,   L897,  L  241. 
Butlin,  Diseases  of  the  Tongue.     1900. 
Cooper,  Bransby,  Guy's  Hosp.  Eepts.,  1837,  ii.  404. 
Da  Costa,  Keen's  Surgery,  hi.  666  (•. 
Dawbarn,   Treatment  of  Certain.   Malignant  Growths   by  Excision  of  the  External 

Carotids.     1903. 
Ducrot,  These  de  Paris,  No.  355,  1879. 
Duplay  and  Reclus,  Traite  de  Chir.,  1898,  v.  144. 
Eve,  Pro,-.  Roy.  Soc.  Med.,  1910. 
Fairbairn,  Med.  Times,  1845,  xii.  392. 
Fayrer,  Clin.  Surg,  in  India,  p.  485.     1866. 
Fournier,  •■  Lscons  sur  les  Syphilides  tcrtiares  de  la  Langue,"   Ecole  de  Medecine, 

Pari-;,   1877. 
Goaiby,  K.  W.,  "  Treatment  of  Pyorrhoea  Alveolaris  by  Vaccines,"  Brit.  Journ. 

Dent.  Sci.,   London,   1905,  xlviii.  562,  963 
Helbing,  Jahrbuch  fur  Kinderheilkunde,  1896,  xl.  442. 
Hennig,  ibid.,  1877,  xxi.  290. 

Jacobson  and  Rowlands,  Operative  Surgery,  i.  588.     1907. 
Johnstone,  Laryngoscope,  St.  Louis,  1908,  xviii.  286-92. 
Keith,  Prof.  A.,  Human  Embryology  and  Morphology,  p.  42.      1904. 
Lapie,  Bull,  de  V  Acad.  Roy.  de  Chir.,  Paris,  1857,  iii!  16. 
Levy,  R.,  "Tuberculosis  of  the  Mouth,"  Amir.  Laryngol.,  Rhinol.  and  Otol.  Soc., 

St.  Louis,  1907.  pp.  253-63. 
Maitland,  Austral.  Med.  Gaz.,  Oct.,  1906. 
Morestin,  "  Leucoplasie  linguale  etendue  traite*  par  la  Decortication,"  Bull,  de 

la  Soc.  Fran?,  de  Derm,  et  de  Syph.,   1908,  xix.  65. 
Morrison,  R.,  "The  Diagnosis  of  some  of  the  Common   Ulcers  of  the  Mouth," 

Brit.  Dent.  Joum.,   1907,  xxviii.   1211-4. 
Parrot,  Progr&s  Mel.,  Paris,  1881,  p.   191. 
Piersol,  Human  Anatomy,  p.  954. 
Pouzergues,  These  de  Paris,  No.  223,  1873. 
Reboul,   Assoc.    Franc,    pour  l'Avancement   des    Sciences,   Gaz.   Hebd.   de   Med.  el 

de  Chir..  L897,  p.  786. 
Sabrazes  et  Bousquet,  Presse  Mel.,  1897,  p.  209. 

Stone,  W.  G.,  "  Lymphangioma  of  the  Tongue,"  Trans.  Clin.  Soc,  1907,  xl.  280. 
Tanturri,  Qiorn.  Ital.  delle  Mai.  Yener.  e  della  Pelle,  1872,  iv. 
Upcott,  "  Operations  on  the  Tonsil,"  Lancet. 
Vanlair,  /!,  v.  M>  ns.  de  Med.  et  de  Chir.,  Paris,  1S80,  p.  54. 
Warren,  J.  C,  "  Cancer  of  the  Mouth  and  Tongue,"  Amer.  Surg.,  Philadelphia, 

L908,   xlviii.   481-514. 
Wharton,  Med.  News,  Philadelphia,  1895,  lxvi.  406. 


THE     SALIVARY    GLANDS    AND     FLOOR    OF 
THE    MOUTH 

By  IVOR  BACK,  M.A.,  M.B.,  B.G.Cantab., 
F.R.C.S.Eng. 

INJURIES    OF    THE    SALIVARY    GLANDS 

THE   PAEOTID    GLAND 

Any  of  the  salivary  glands  may  be  involved  in  an  injury,  but  it  is 
the  parotid  which  is  most  frequently  damaged  in  this  way,  on 
account  of  its  comparatively  exposed  situation.  The  injury  may  be 
inflicted  wilfully,  as  by  stabbing  or  gunshot  wounds,  or  accidentally, 
as  during  the  course  of  a  surgical  operation.  Armstrong  of  Montreal 
has  recorded  a  case  in  which  he  accidentally  injured  the  submaxillary 
gland  while  attempting  to  enucleate  an  overlying  tuberculous  gland. 
A  fistula  resulted  which  only  closed  after  two  further  operations,  in 
which  the  fistulous  track  was  excised  and  the  edges  were  approximated 
by  deep  sutures.  Injuries  involving  the  submaxillary  or  sublingual 
gland  are  of  far  less  serious  import  than  those  in  which  the  parotid 
is  concerned,  because  if  a  permanent  fistula  results  the  gland  can 
be  excised  completely  with  comparative  ease  and  slight  resulting 
disfigurement.  But  the  parotid  gland  is  so  intimately  connected 
with  important  structures  that  such  a  proceeding  is  rarely  justifiable 
in  its  case  unless  the  surgeon  is  dealing  with  a  malignant  new  growth 
whose  presence  will  inevitably  cause  the  death  of  the  patient.  Injuries 
to  the  parotid  may  be  subdivided  according  to  whether  the  gland 
substance  itself  is  injured,  or  its  duct  only. 

Injuries  of  the  Parotid  Gland  Substance 

The  tissue  of  the  parotid  gland  is  frequently  incised  during  the 
course  of  surgical  operations  in  the  neck,  but  primary  union  nearly 
always  follows  if  the  wound  is  closed  with  deep  stitches,  and  a  salivary 
fistula  from  this  cause  is  uncommon. 

Treatment. — In  dealing  with  an  external  wound  of  the  parotid 
gland  substance,  the  first  duty  of  the  surgeon  is  to  exclude  the  presence 

234 


THE    PAROTID   GLAND  235 

of  injury  t<>  the  important  structures  which  traverse  the  gland,  parti- 
cularly the  facial  nerve.  The  trunk  of  the  transverse  facial  artery  or 
mimic  of  its  branches  may  be  severed,  so  t  hat  t here  is  likely  to  be 
haemorrhage.  This  must,  of  course,  be  arrested,  and  the  wound  sewn 
up.  The  importanl  point  to  observe  is  that  the  sutures  must  pass 
down  into  the  depths  of  the  wound  so  that  all  the  divided  tissue  is 
included:  otherwise,  pockets  may   form  which  will   prevent  healing. 

If  the  edues  are  ja<j<jcd  the  contused  portions  must  be  cut  away. 
A  firm  bandage  should  then  he  applied.  The  patient  should  he  kepi 
mi  a  simple  diet  which  does  not  demand  mastication,  ami  talking 
should  be  forbidden  until  the  wound   is  healed. 

Injuries  of  the  Parotid  Duct  (Stenson's  Du<  m 

Stenson's  duct  is  liable  to  injury  in  vertical  wounds  of  the  face 
which  cross  its  course  at  right  angles.  The  wound  may  or  may  nor 
perforate  the  cheek  and  form  an  opening  into  the  mouth.  The 
prognosis  is  better  in  the  former  case,  since  if  primary  union  of  the 
divided  ends  does  not  occur  (and,  in  spite  of  the  statements  of 
Konig,  it  rarely  does  occur)  there  is  a  possibility  that  the  resulting 
fistula  may  become  an  internal  one,  and  a  spontaneous  cure  be  thus 
effected. 

AYhen  the  wound  has  been  cleaned  and  the  haemorrhage  arrested, 
the  divided  ends  of  the  duct  will  be  seen  protruding  from  the  cut 
surfaces.  The  circumference  of  the  duct  is  so  small  that  partial 
division  of  it  is  rare. 

Treatment.  —  Konig  believes  that  many  such  injuries  have 
remained  unrecognized,  and  that  primary  union  of  the  duct  has 
occurred  spontaneously.  He  maintains,  therefore,  that  it  is  the.  duty 
of  the  surgeon  to  unite  the  divided  ends  with  fine  catgut  sutures,  and 
close  the  external  wound.  If  any  wound  is  present  in  the  mucous  mem- 
brane it  should  be  left  open.  He  lays  stress  on  the  importance  of  the 
after-treatment  described  in  connexion  with  wounds  of  the  parotid 
gland  itself  (see  above).  This  operation  is  one  of  extreme  difficulty  in 
view  of  the  diminutive  circumference  of  the  duct,  and,  in  my  opinion, 
primary  union  rarely,  if  ever,  occurs.  Moreover,  if  it  fails,  an  external 
fistula  is  bound  to  ensue  if  the  original  wound  was  a  non-penetrating 
one.  A  better  chance  of  obtaining  a  successful  result  is  ensured  by 
converting  a  non-penetrating  wound  into  a  penetrating  one  by  in- 
cising the  mucous  membrane.  The  external  wound  is  then  accurately 
closed.  In  the  case  of  a  wound  which  originally  penetrated  the 
mouth,  closure  of  the  external  wound  is  all  that  is  necessary.  In  a 
certain  proportion  of  cases  the  external  wound  remains  closed,  and 
an  internal  fistula  is  formed,  which,  as  far  as  functional  activity  is  con- 
cerned, will  answer  all  the  purposes  of  the  normal  orifice  of  the  duct. 


23<5  THE   SALIVARY   GLANDS 

SALIVARY   FISTULA 

The  term  salivary  fistula  is  here  taken  to  indicate  an  external 
fistula  through  which  the  secretion  is  discharged  on  to  the  surface 
of  the  cheek.  Internal  fistula?  exist,  and  are  sometimes  congenital. 
Bochdalek  described  one  in  which  the  opening  into  Wharton's  duct 
was  eleven  lines  behind  the  sublingual  caruncle.  But  the  condition 
does  not  present  any  surgical  interest,  since  it  causes  the  patient  no 
inconvenience. 

An  external  fistula,  on  the  other  hand,  may  render  his  existence 
miserable.  The  constant  discharge  of  saliva,  aggravated  as  it  is  at 
meal-times,  may  render  him  objectionable  to  his  fellow-men,  so  that 
he  is  compelled  to  satisfy  his  hunger  in  solitude.  Further,  the  orifice 
of  the  fistula  is  often  surrounded  by  an  eczematous  area  from  the 
constant  irritation  of  the  fluid  dribbling  over  the  cneek.  It  has  been 
said  that  the  continual  loss  of  salivary  fluid  may  impair  the  health 
of  the  patient.  It  is  hard  to  believe  this,  though  it  is  known  that 
the  amount  excreted  may  assume  large  proportions.  Two  classical 
experiments  prove  this.  Duphenix  collected  from  a  salivary  fistula 
70  grammes  of  fluid  in  fifteen  minutes,  and  a  patient  of  Jobert's  dis- 
charged "  several  cupfuls  "  in  twenty- four  hours. 

A  persistent  salivary  fistula  usually  results  from  one  of  the  injuries 
already  described.  It  may  have  been  originally  neglected  or  in- 
adequately treated  ;  or  attempts  to  obtain  primary  union  may  have 
been  made  and  have  failed.  The  principal  conditions  which  militate 
against  primary  union  are  sepsis  occurring  in  the  original  wound,  or 
severe  contusion  of  its  edges.  In  the  case  of  an  injury  to  Stenson's 
duct,  primary  union  of  the  wound,  even  though  its  edges  were  clean- 
cut  and  it  remained  aseptic  throughout,  must  be  regarded  as  the 
exception  rather  than  the  rule,  and  an  obstinate  fistula  often  results. 

Salivary  fistula?  are  also  caused  occasionally  by  ulcerative  processes 
invading  the  tissues  of  the  cheek,  e.g.  rodent  ulcer,  lupus,  and  actino- 
mycosis. 

Treatment.  —  For  practical  purposes,  salivary  fistula?  may  be, 
divided    into    two    main    classes,    the    second    of    which    is    again 
divisible. 

1.  Gland  fistula?,  communicating  with  the  gland  substance.    " 

2.  Duct  fistula?,  communicating  with  the  duct  (i)  as  it  lies  over 

the  masseter  muscle  (masseteric),   (ii)  as  it  lies  in  front 
of  the  anterior  border  of  the  masseter  (buccal). 
1.  Gland    fistulae. —  The    treatment    is    usually    rewarded    with 
success,  though  patience  is  demanded  on  the  part  of  the  patient,  and 
perseverance  on   that   of  the   surgeon.     Cauterization  with   a   silver- 
nitrate    stick    should    first    be    given    a    prolonged  trial.     It  should 


SALIVARY    FISTULjE:    TREATMENT  237 

be  done  every  alternate  day,  and  a  Eairly  linn  bandage  applied. 
Kiiithcr  Btatea  thai  the  actual  cautery  is  more  efficacious.  II 
these  measures  fail  after  a  reasonably  long  trial,  the  whole  fistulous 
track  slmuM  be  excised,  and  the  edges  brought  together   with    deep 

sutures  which  include  all  the  exposed  tissue;  in  other  words  after  ex- 
cision of  the  hack,  the  resulting  wound  must  be  treated  m  the  same 
way  as  a  primary  wound  of  the  eland.  Care  must,  of  course,  be  taken 
not  to  cut   any  branches  of  the  facial  nerve  during  the  operation. 

2.  Duct  fistulae. — The  cure  of  a  duct  fistula  is  a  much  more 
tedious  and  difficult  business.  The  variety  of  procedures  which  have 
been  advocated  from  time  to  time,  and  the  ingenuity  which  has  been 
expended  in  devising  them,  furnish  evidence  that  there  is  no  royal 
road  to  success. 

The  several  methods  which  have  been  described  come  under  two 
main  headings — (a)  those  in  which  an  attempt  is  made  to  restore  the 
natural  aqueduct,  and  (b)  those  in  which  an  attempt  is  made  to  convert 
an  external  into  an  internal  fistula.  If  their  respective  merits  are 
regarded  from  an  academic  point  of  view,  there  can  be  no  doubt 
that  the  former  is  preferable,  since  it  aims  at  restoring  a  natural  state 
of  affairs  ;  but,  practically,  the  chances  of  success  by  this  method  are 
so  small,  that  I  am  of  opinion  that  the  second  is  the  method  of  choice 
for  the  treatment  of  duct  fistulae. 

Armstrong  of  Montreal  gives  a  clear  account  of  the  method  of 
Nicoladoni,  who  is  the  chief  exponent  of  the  first  method.  He  writes  : 
"  Nicoladoni  has  successfully  joined  the  ends  of  the  divided  duct 
after  removing  the  scar  tissue.  AVhen  there  is  a  considerable  gap, 
he  incises  the  cheek,  picks  up  the  proximal  end  of  the  peripheral  portion, 
and  frees  it  from  the  buccinator  up  to  the  caruncle  ;  then,  by  making 
a  crescentic  incision  through  the  buccal  mucosa  in  front  of  the  caruncle, 
he  is  able  to  displace  the  duct  orifice  as  much  as  1*5  cm.  towards  the 
gland,  and  so  approximate  the  ends  of  the  divided  duct  that  he  can 
unite  them  through  an  external  incision."  It  is  obvious  that  this 
method  is  ideal  if  it  can  succeed.  But,  since  it  rarely  does  so 
even  in  a  primary  woimd  of  the  duct,  how  much  less  is  the  chance 
of  its  doing  so  in  an  old-standing  injury,  when  the  ends  have  become 
widely  separated  and  the  peripheral  portion  of  the  duct  has  usually 
ceased  to  be  permeable  ! 

The  simplest  method  of  converting  an  external  into  an  internal 
fistula  is  that  described  and  employed  by  Deguise  in  France  and  Pearce 
Gould  in  this  country.  It  consists  in  passing  a  strong  suture  (either 
silk  or  silver  wire)  from  the  fistula  through  the  buccal  mucous  membrane 
in  two  places,  one  Oo  cm.  behind  the  other  (Fig.  342).  The  ends  which 
now  protrude  in  the  mouth  are  tied  very  tightly.  The  tissue  enclosed 
necroses,    and   thus    an   internal    opening   is   formed.      The   external 


238 


THE   SALIVARY   GLANDS 


fistula  then  closes  of  its  own  accord.  But,  to  make  assurance  doubly- 
sure,  tlie  edges  of  the  fistula  may  be  pared  and  united  with  one  or  two 
fishing-gut  sutures.  This  method  has  obvious  limitations.  It  cannot, 
for  instance,  be  used  in  a  masseteric  fistula,  since  it  would  be  necessary 
to  include  the  muscle  in  the  ligature,  and  this  is  not  feasible. 

Kaufmann  has  devised  a  modification  of  this  method.     The  cheek 
is  perforated  opposite  the  fistula,  and   a   small   rubber  tube  3  mm. 


Fig.  342. — Operation  for  fistula  of  salivary  duct. 

thick  is  drawn  through  so  that  it  projects  both  internally  and  ex- 
ternally. At  the  end  of  a  week  it  is  cut  down  on  both  sides  so  that 
it  is  flush  with  skin  and  mucous  membrane.  In  another  week  it  is 
removed  entirely.  He  claims  that  the  saliva  will  now  flow  into  the 
mouth  through  the  artificial  orifice,  and  that  the  external  fistula  will 
close,  especially  if  it  is  cauterized  from  time  to  time,  or  its  edges  are 
approximated  by  suture.  The  technique  is  extremely  simple.  One 
practical  point  must  be  observed  :  the  tube  must  fit  tightly  in  the 
perforation  in  the  mucous  membrane,  or  it  will  not  remain  in  position. 
This  method  has  one  advantage  over  Deguise's.  By  making  the 
track  of  the  tube  oblique,  so  that  it  enters  the  mouth  in  front  of  the 
masseter,  it  is  applicable  to  masseteric  fistula?,  whereas  Deguise's 
method  can  only  be  applied  to  the  buccal  variety  with  any  prospect 
of  success. 


SIALO-ADENITIS  239 

None  of  the  methods  of  dealing  mth  a  salivary  fistula  described 
can  be  regarded  as  infallible;  and  if,  after  a  patient  trial,  a  curi 
not  effected,  the  question  of  arresting  the  salivary  secretion  altogether 
must  be  considered.  Two  methods  of  doing  this  have  been  described. 
Bramann  lias  ligatured  the  duel  on  the  proximal  side  of  the  fistula 
in  three,  eases,  and  in  two  of  them  the  result  was  satisfactory.  But 
he  allows  that  a  certain  amount  of  risk  is  attached  to  it;  for  instance, 
the  gland  may  become  swollen  from  retention  of  its  products,  and 
abscess-formation  may  develop  secondarily.  The  other  alternative  is 
to  dissect  out  as  much  of  the  gland  as  possible,  taking  care  not  to 
damage  the  facial  nerve.  This  will  necessarily  lead  to  some  disfigure- 
ment, but  that  is  preferable  to  the  distressing  phenomena  associated 
with  a  persistent  salivary  fistula. 

DISEASES  OF  THE  SALIVARY  GLANDS 

INFLAMMATION 

Etiology. — The  etiology  of  sialo-adenitis  is  still  a  vexed  question. 
It  used  to  be  held  that  the  salivary  glands  were  liable  to  infection 
apart  from  any  exciting  or  predisposing  condition  ;  but  recent  re- 
searches have  modified  our  ideas  upon  the  matter.  It  is  now  agreed 
that  there  are  few,  if  any,  inflammatory  conditions  of  the  salivary 
glands  which  are  not  primarily  due  to  an  ascending  infection  from  the 
mouth  along  the  duct. 

The  etiology  of  sialo-adenitis  as  it  is  understood  to-day  may 
be  compared  with  that  of  appendicitis.  The  appendix  is  normally 
inhabited  by  the  Bacillus  coli  communis.  If  stagnation  occurs  in  it 
as  the  result  of  kinking,  or  the  presence  of  a  stercolith,  its  resistance 
to  infection  is  diminished,  and  the  bacillus  at  once  becomes  a 
toxic  instead  of  a  benign  organism,  and  acute  appendicitis  is 
the  direct  outcome.  In  the  same  way  the  mouth  is  normally  in- 
habited by  a  number  of  mixed  micro-organisms.  As  long  as  the 
salivary  glands  function  adequately,  these  organisms  are  inert ;  but 
if  there  is  any  diminution  of  the  salivary  activity,  as  occurs  in  pyrexia 
or  after  laparotomy  (Pawlow  has  experimentally  proved  that  this 
is  a  constant  phenomenon  in  dogs),  an  ascending  infection  along  the 
ducts  immediately  follows. 

Ginner  has  tabulated  the  results  of  bacteriological  examination 
in  52  cases  of  suppurative  parotitis,  as  follows  : — 

Staphylococcus  aureus.          .     28  Pneumobacillus            .          .  *■ 

Staphylococcus  albus    .          .       2  Micrococcus  tetragenus        .          .  - 

Pneurnococcus      .          '.          .11  Bacillus  typhosus        .                    .  2 

Streptococcus       ...       5  Elongated  bacillus  (unclassifiable)  1 


24o  THE   SALIVARY   GLANDS 

This  table  may  be  regarded  as  evidence  in  favour  of  the  view  that 
sialo-adenitis  is  nearly  always,  if  not  always,  an  ascending  infection, 
since  most  of  the  micro-organisms  mentioned,  except  the  last,  have 
been  found  in  an  apparently  healthy  oral  cavity.  Epidemic  parotitis, 
the  organism  of  which  has  not  been  definitely  isolated,  is  alone  in- 
explicable upon  this  hypothesis,  but  even  in  this  case  there  is  generally 
a  prodromal  stage  of  stomatitis,  which  is,  at  any  rate,  presumptive 
evidence  in  favour  of  the  view  that  it  is  an  ascending  infection.  It 
must  be  confessed,  however,  that  the  secondary  implication  of  the 
testis,  which  is  so  characteristic  a  feature  of  the  disease,  cannot  be 
explained  on  such  simple  grounds.  It  must,  on  our  present  know- 
ledge, be  regarded  as  an  infection  by  way  of  the  blood-stream. 
We  are,  therefore,  compelled  to  recognize  two  forms  of  acute  sialo- 
adenitis. 

1.  Primary  Acute  Sialo- Adenitis 

Epidemic  parotitis  is  a  highly  infectious  disorder,  attacking 
adolescents.  It  is  said  that  males  are  more  commonly  attacked 
than  females. 

The  incubation  period  is  long  (sixteen  to  twenty-one  days  or 
more,  even  up  to  six  weeks).  The  onset  is  characterized  by  pyrexia, 
generally  not  higher  than  101°,  and  pain  below  the  ear.  In  a  day 
or  two,  one  parotid  gland  begins  to  swell,  and  its  outline  becomes 
obvious.  The  skin  over  it  is  tense  and  cedematous.  A  day  or  two 
later  the  gland  on  the  opposite  side  follows  suit.  The  course  of 
the  disease  is  generally  benign.  The  temperature  falls  in  a  week, 
and  the  swelling  then  begins  to  recede  gradually.  It  usually  dis- 
appears completely  in  a  month,  but  sometimes  induration  remains 
for  a  longer  period. 

The  treatment  is  simple.  The  patient  should  be  kept  in  bed, 
and  a  cold  compress  be  applied  to  the  swollen  gland.  Occasionally, 
suppuration  occurs  in  the  parotid  ;  an  abscess  must  be  incised  as 
soon  as  its  presence  is  diagnosed. 

One  of  the  most  interesting  features  of  the  disease  from  a  surgical 
point  of  view  is  the  inflammation  of  the  testis  which  sometimes  is 
a  complication.  The  treatment  of  the  orchitis  is  identical  with  that 
of  the  parotitis.  Atrophy  of  the  affected  testis,  even  if  spontaneous 
resolution  occurs,  supervenes,  according  to  Kocher,  in  one-third  of 
the  cases  ;  and  if  the  orchitis  has  been  bilateral,  sterility  often  results. 
Other  glands  may  be  similarly  affected;  they  are  the  pancreas,  the 
lachrymal  glands,  and,  in  the  female,  the  ovary  and  mamma. 

2.  Secondary  Acute  Sialo-Adenitis 

This  differs  from  the  primary  form  in  running  a  more  acute  course  ; 
in  fact,  suppuration  is  the  rule. 


si  GOND  \KV    ACT  IT     SIM  I  >-  \DI    \|  I  IS    .  Z41 

The  predisposing  conditions  may  be  divided  mi"  three  main 
classes  : — 

i.  Abnormal  conditions  of  tin-  oral  cavity,  particularly  all  forms 

of   stomatlti-. 

ii.  Acute  diseases,  such  a-  typhus,  variola,  pneumonia,  typhoid, 
and  pysemia.  Less  acute  disorders  have  also  been  known  to  cause 
it.  In  carcinoma  it  is  not  uncommon,  and  in  a  case  of  Klippel's  it 
was  a  complication  of  tabes.     Carr  bas  recorded  an  attack  of  acute 

grenous  parotitis,  a-  a  terminal  event,  in  a  case  of  granular  kidney. 

iii.  Abdominal  disease.  Attention  was  firsl  directed  to  the 
ciation  of  a<ute  parotitis  with  abdominal  disease  in  cases  in  which 
ovariotomy  had  been  performed.  In  view  of  the  observation  that 
epidemic  parotitis  was  often  followed  by  orchitis  and  oophoritis,  it 
was  at  first  presumed  that  there  was  some  sympathetic  connexion 
between  the  two  sets  of  organs,  and  that  one  responded  reflexly  to 
disease  or  injury  of  the  other.  Stephen  Paget  collected  101  cat 
of  parotitis  following  upon  disease  of  the  abdomen  or  pelvis  ;  and  of 
these  "50  were  due  to  injury,  disease,  or  temporary  derangement 
of  the  genital  organs,"  a  percentage  which  lent  colour  to  the  hypothesis. 
This  view  is  not  generally  held  now.  After  laparotomy,  as  in  pyrexia, 
the  mouth  i>  dry  and  there  is  diminished  salivary  secretion,  so  that 
the  glands  are  in  a  state  which  renders  them  particularly  liable  to 
infection.  Further  investigation  has  shown  that  the  abdominal  cases 
which  are  most  constantly  followed  by  parotitis  are  those  in  which 
rectal  feeding  is  necessary,  such  as  gastric  ulcer.  In  patients  who 
are  being  rectally  fed  the  mouth  readily  becomes  septic  in  spite  of 
the  most  skilful  care  and  attention,  and  the  infection  spreads  up  to 
the   elands  along  the  duct-. 

3  1  'lidary  acute  inflammation  is  confined  almost  entirely  to  the 
parotid.  When  it  occurs  after  laparotomy,  the  swelling  of  the  parotid 
begins  about  the  end  of  the  first  week.  In  connexion  with  other 
di-eases  no  definite  date  can  be  stated.  The  lower  pole  of  the  parotid 
generally  enlarge-  first,  but  soon  the  swelling  involves  the  whole  gland, 
so  that  the  side  of  the  face  is  broadened  and  the  ear  is  pushed  out. 
The  skin  over  the  parotid  is  at  first  tense,  but  later  becomes  red 
and  oedematous.  with  dilated  veins  running  over  the  swelling.  Gi 
pain  is  experienced  by  the  patient  because  the  eland  is  covered  by 
dense,  unyielding  fascia,  and  the  tension  of  the  parts  i-  considerable. 
General  malaise  is  complained  of,  and  the  temperature  is  always 
raised  ;    it  may  teach   1m",  . 

Treatment.  —  Spontaneous  subsidence  may  begin  about  the 
fourth  day  from  the  onset  of  symptoms  :  but  this  is  an  unusual 
termination.  In  the  majority  of  case-  -uppuration  supervene-.  It 
i>   very  difficult  to  decide  in   any  given   case   whether  an  absces- 

9 


242       .  THE   SALIVARY   GLANDS 

present  or  not.  Owing  to  the  denseness  of  the  fascia  over  the  parotid, 
the  ordinary  signs  of  an  abscess,  a  red,  fluctuating  swelling,  may  be 
entirely  absent.  In  my  opinion,  an  incision  should  be  made  into  the 
swelling  in  every  case  in  which  the  symptoms  have  steadily  increased 
in  severity  or  have  even  persisted  without  abatement  for  five  days 
or  longer.  In  making  the  incision,  regard  should  be  had  to  the  course 
of  the  facial  nerve.  Even  if  no  abscess  is  foimd,  the  tension  will 
be  relieved  by  division  of  the  deep  fascia.  If  a  localized  abscess  is 
discovered,  it  should  be  drained  by  means  of  a  rubber  tube,  and  hot 
fomentations  should  be  applied.  In  other  cases  no  definite  abscess 
can  be  found,  but  the  whole  gland  is  disintegrated  and  infiltrated 
with  pus  (this  was  the  state  of  the  gland  in  Carr's  case,  already  quoted). 
In  these  circumstances  the  prognosis  is  extremely  grave,  and  a  fatal 
termination  must  be  expected. 

If  relief  is  not  afforded  by  early  surgical  interference,  a  parotid 
abscess  may  travel  and  point  in  several  directions.  Most  commonly 
it  makes  its  way  backwards  and  discharges  its  contents  through  the 
external  auditory  meatus  ;  or  it  may  burrow  behind  the  pharynx 
and  oesophagus,  and  extend  into  the  mediastinum. 

Beveridge  has  recorded  a  case  in  which  a  parotid  abscess  travelled 
upwards  behind  the  zygoma,  and  pointed  in  the  temporal  fossa.  Other 
untoward  results  which  have  been  observed  are  complete  destruction  of 
the  facial  nerve  and  thrombosis  of  the  jugular  vein  and  lateral  sinus, 
with  extension  of  the  septic  process  to   the  interior  of  the  cranium. 

SUBACUTE    AND    CHRONIC    INFLAMMATION    OF    THE 
SALIVARY   GLANDS 

This  condition  is  very  rare  apart  from  inflammation  of  the  duct ; 
in  fact,  to  Kiittner  alone  we  owe  our  knowledge  of  it.  According  to  him, 
it  is  only  found  in  the  submaxillary  glands,  which  become  enlarged 
so  as  to  form  an  oval  swelling.  This  tends  to  enlarge  in  size,  and  to 
become  adherent  to  surrounding  tissues  ;  for  this  reason  Kiittner 
advises  enucleation  of  the  affected  glands.  When  examined  micro- 
scopically they  are  found  to  contain  foci  of  granulation  tissue  and 
small  abscesses.  The  chief  point  of  clinical  interest  is  the  difficulty 
of  diagnosing  the  condition  from  a  sarcoma  or  a  gumma. 

INFLAMMATION    OF    THE    SALIVARY   DUCTS 

The  salivary  ducts  are  liable  to  inflammation  from  the  same  causes 
which  produce  parotitis,  i.e.  septic  conditions  of  the  mouth.  The 
condition  is  peculiarly  prone  to  occur  in  any  form  of  xerostomia. 

A  series  of  cases  of  this  nature  has  been  reported  by  Raymond 
Johnson.  The  patients  sought  advice  on  account  of  a  swelling  of 
one  parotid  gland,  which  was  painful  and  became  larger  at  mealtimes. 


SALIVARY   CALCULI 

Borne  of  them  had  discovered  for  themselves  thai  pressure  on  the 
Bwelling  caused  a  discharge  of  watery  fluid  into  the  mouth,  with  .1 
temporary  relief  of  1  he  symptoms. 

On  examination,  the  orifice  of  the  duct  of  the  affected  gland  was 
found  red  and  inflamed,  and,  in  some  cases,  stood  up  like  a  papilla. 
Pressure  on  the  swelling  caused  firsl  the  extrusion  <>l'  a  plug  <>l  mucus 
from  the  duel,  followed  by  a  flow  of  watery  saliva.  In  the  way  of 
treatment,  relief  is  obtained  by  the  application  "I  dry  heal  exter- 
nally, with  frequent  use  of  ho1  mouth-washes  combined  with  the  peri- 
odica] passage  of  a  probe  along  the  duct.  Raymond  Johnson  followed  up 
tlic  history  of  his  cases  and  found  thai  the  swelling  usually  took  some 
months  to  disappear ;  and  in  certain  instances  reappeared  al  intervals, 
although  the  attacks  tended  to  decrease  in  severity.  In  his  opinion, 
the  enlargement  <>f  the  gland  is  due  entirely  to  obstruction,  and  uo1 
to  any  secondary  inflammation  in  it.  In  sonic  cases  ii  is  certain  that 
if  an  inflamed  duct  becomes  stenosed  by  fibrosis,  the  enlargement 
of  the  gland  is  then  very  chronic,  if  not  absolutely  persistent.  Tin- 
only  measure  thai  is  of  any  avail  is  to  slit  up  the  fibrosed  duct  into 
the  buccal  cavity. 

SALIVARY   CALCULI 

The  genesis  of  a  salivary  calculus  is  so  intimately  connected  with 
inflammation  of  the  duct,  that  the  condition  may  well  be  considered 
ai  this  juncture.  The  mode  of  formation  is  analogous  to  that  of 
calculi  in  other  parts — the  gall-bladder,  for  instance.  As  the  result 
of  the  sialo-ductitis  a  plug  of  mucus  containing  bacteria  is  retained 
within  the  duct,  and  forms  a  nucleus  for  the  successive  deposits  of 
inorganic  salts,  principally  the  phosphate  and  carbonate  of  lime. 

Calculi  are  more  often  found  in  the  ducts  of  the  sublingual  and 
submaxillary  glands  than  in  that  of  the  parotid.  This  is  only  what 
might  be  expected,  seeing  that  their  secretion  is  viscid  and  highly 
charged  with  salts,  while  that  of  the  parotid  is  more  watery.  They 
are  greyish-white  in  colour,  and  generally  ovoid  in  shape,  like  the  stone 
of  an  olive.     Their  surface  is  usually  roughened. 

A  salivary  calculus  may  exist  for  a  considerable  time  without  giving 
rise  to  symptoms  ;  but  as  the  stone  gradually  enlarges,  it  will  eventu- 
ally obstruct  the  duct  more  completely.  When  this  occurs,  periodic 
enlargements  of  the  affected  gland  will  be  noticed,  particularly  at 
mealtimes,  owing  to  the  obstruction  to  the  discharge  of  the  secretion. 
The  patient  complains  of  pain,  occasionally  of  a  quite  acute  nature. 
so  that  French  writers  have  given  the  name  "  coliques  salivaires  to 
these  attacks. 

Suppuration  may  occur  round  the  stone,  as  it  lies  in  the  duct  ; 
a  circumstance  which  can  be  diagnosed  by  the  periodic  discharge  of 


244  THE   SALIVARY   GLANDS 

pus  into  the  mouth.  .More  rarely,  the  stone  may  ulcerate  through 
the  wall  of  the  duct  either  into  the  mouth  or,  in  the  case  of  a  stone 
in  Stenson's  duct,  externally,  giving  rise  to  a  salivary  fistula. 

Calculi  may  also  be  situated  in  the  substance  of  one  of  the  salivary 
glands.  In  this  position  they  are  nearly  always  small  and  multiple, 
and  each  calculus  is  surrounded  by  a  small  abscess.  In  such  a  case 
the  gland  is  chronically  enlarged  and  tender,  and  there  is  a  more 
or  less  constant  escape  of  pus  into  the  mouth. 

The  diagnosis  is  not  a  matter  of  difficulty  in  the  absence  of  secondary 
septic  changes.  In  most  cases,  the  calculus  can  easily  be  felt  as  a 
hard  body  through  the  mucous  membrane,  on  bimanual  examination. 
But  if  acute  inflammation  has  supervened,  the  true  cause  may  easily 
be  overlooked,  and  the  case  treated  as  one  of  septic  adenitis  due  to 
an  ascending  infection.  To  avoid  this  error,  an  attempt  should  always 
be  made  to  probe  the  affected  duct.  Alsberg  states  that  an  X-ray 
examination  is  of  material  assistance. 

Treatment.  —  If  the  stone  lies  in  the  duct,  this  is  easy.  All 
that  is  necessary  is  to  slit  up  the  mucous  membrane  and  remove  the 
calculus  with  forceps.  Antiseptic  mouth- washes  should  be  prescribed. 
The  symptoms  will  rapidly  abate,  even  in  cases  in  which  sepsis  has 
supervened.  Calculi  in  the  gland  are  not  so  easily  dealt  with.  If  the 
affected  gland  is  the  submaxillary,  it  is  best  to  enucleate  it  entirely  ; 
but  in  the  case  of  the  parotid  this  is  not  feasible.  Here  an  incision 
must  be  made  and  the  calculi  extracted,  care  being  taken  of  the  facial 
nerve.  A  gland  fistula  may  result ;  this  must  be  subsequently  treated 
in  the  manner  already  described. 

ACTINOMYCOSIS,    TUBERCULOSIS,    SYPHILIS,    MIKULICZ'S 

DISEASE 

The  infective  granulomata  very  rarely  attack  the  salivary  glands. 
Actinomycosis  has  not  been  recorded  as  a  primary  infection,  but 
any  of  the  salivary  glands  may  become  implicated  by  a  direct  ex- 
tension from  the  disease  when  it  starts  in  the  face  or  jaw. 

Tuberculosis  is  also  exceedingly  rare ;  only  about  a  dozen 
cases  have  been  recorded  in  all.  The  main  clinical  interest  lies  in 
the  difficulty  of  diagnosing  the  condition  from  subacute  septic  in- 
flammation. Too  much  reliance  should  not  be  placed  on  the  tuberculin 
reaction.  The  only  positive  method  of  diagnosis  is  microscopical 
examination  of  a  portion  of  the  enlarged  gland  removed  by  operation. 
The  clinical  history  closely  resembles  that  of  tuberculosis  of  lymphatic 
glands,  i.e.  the  enlargement  is  chronic,  but  cold  abscess  formation  is 
prone  to  occur.  Treatment  consists  in  draining  the  abscess  or  in 
partial  removal  of  the  parotid  or  total  excision  of  the  submaxillary 
gland,  according  to  the  pathological  condition  present,  and  its  position. 


MIKULICZ'S   DIM    \M  2j5 

Syphilis  attacking  the  Balivary  glands  is  also  ran.  the  whole 
of  medical   literature  affording  only  some   twenty-fiv<  li    \i 

a  late  manifestation,  gumma  formation  or  interstitial  fihro.-i-.  being 
the  usual  manifestation.  Neumann  has,  however,  reported  fiv< 
occurring  in  the  6rs1  year  <>l  the  disease.  Ii  used  u>  !><•  said  that  the 
diagnosis  was  only  possible  in  the  presence  of  other  manifestations 
of  syphilis,  hut  it  can  now  be  made  absolute  with  the  aid  of  the 
Wassermann  reaction.  No  special  treatment,  other  than  general 
antisyphilitic  remedies,  is  required. 

Mikulicz's  disease  is  a  rare  condition,  which  has  been 
described  as  a  clinical  entity  by  von  Mikulicz  of  Breslau.  It  consists 
of  a  symmetrical  enlargement  of  the  salivary  and  lachrymal  glands. 
Other  gland-,  according  to  subsequent  observers,  may  also  be  involved, 
e.g.  the  labial  and  buccal  glands,  and  the  gland  of  Blandin  and  Nuhn. 

The  enlargement  begins  in  early  adult  life,  without  apparent  cause, 
and  is  steadily  progressive  ;  the  parotid  may  enlarge  to  the  size  of 
a  mans  fist.  The  swellings  are  firm  or  elastic  to  the  touch,  but  do 
not  fluctuate,  nor  are  they  tender.  Disfigurement  and  inconvenience 
due  to  the  local  enlargement  are  common,  but  life  is  not  endangered. 
Arsenic  and  potassium  iodide  have  produced  improvement  in  some 
cases,  in  others  the  disfigurement  has  been  sufficient  to  call  for  ex- 
tirpation of  the  affected  glands.     There  is  no  tendency  to  recurrence. 

The  pathology  of  the  condition  is  extremely  obscure.  Micro- 
scopically the  glands  show  an  infiltration  of  round  cells.  Mikulicz 
himself  regards  it  as  being  "  a  new  formation  of  lymphadenoid  tissue 
which  is  spread  round  the  acini  as  centres,  and  leads  to  the  destruction 
of  the  specific  gland  tissue."  Tietze's  view  is  that  it  is  an  "  adenoid 
proliferation  of  the  lachrymal  and  salivary  glands."  Other  authorities 
lean  to  the  view  that  it  is  a  chronic  infective  process.  In  no  case 
has  any  relation  to  syphilis  or  tubercle  been  demonstrated. 

CYSTS    OF   THE    SALIVARY  DUCTS   AND   GLANDS 

Cysts  of  the  Ducts 

Retention  cysts  are  known  to  occur  in  connexion  with  both 
salivary  ducts  and  glands.  Cysts  in  Stenson*s  or  Wharton's  duct 
may  result  from  definite  obstruction  due  to  a  calculus  or  to  cicatricial 
fibrosis  of  the  orifice  ;  but  they  are  occasionally  found  when  there  is 
no  appreciable  obstruction  to  the  outflow  of  secretion,  as  evidenced 
by  a  discharge  of  salivary  fluid  from  the  duct  when  an  irritant  fluid 
such  as  vinegar  is  placed  in  the  mouth.  In  such  a  case,  it  must  t>n 
supposed  that  the  cyst  is  a  collection  of  fluid  in  a  congenital  dilatation 
of  the  duct,  just  as  a  saphenous  varix  is  a  congenital  dilatation  of  the 
vein  rather  than  an  enlargement  due  to  obstruction.     The  cyst  may 


246  THE   SALIVARY   GLANDS 

become  septic  owing  to  an  ascending  infection  from  the  mouth  ;  and 
the  condition  will  then  closely  resemble  that  described  in  connexion 
with  a  salivary  calculus.  In  certain  cases  phosphate  and  carbonate 
of  lime  are  deposited  on  the  walls  of  the  cyst,  and  the  diagnosis  from 
a  salivary  calculus  is  hardly  possible. 

In  an  uncomplicated  case  the  diagnosis  should  be  easy.  An 
ovoid  tumour  can  be  seen  lying  in  the  position  of  the  duct,  with  its 
long  axis  parallel  to  the  line  of  the  duct.  If  it  is  picked  up  between 
the  fingers  it  will  be  felt  to  contain  fluid.  Firm  pressure  will  expel 
its  contents,  and  the  walls  will  fall  into  apposition. 

The  most  efficient  treatment  is  to  make  an  incision  in  the 
mucous  membrane  and  dissect  the  cyst  out  entirely.  The  wound 
in  the  mucous  membrane  should  be  left  open. 

Cysts  of  the  Glaxds 

More  rarely,  retention  cysts  form  in  the  salivary  glands  them- 
selves. They  commence  as  such  in  one  or  more  of  the  smaller  ducts. 
If  multiple  they  coalesce  and  tend  eventually  to  form  a  cyst  of  con- 
siderable size.  In  the  early  stages  it  is  not  easy  to  make  certain  of 
their  presence,  but  later  they  tend  to  come  to  the  surface  and  form 
a  superficial  fluctuating  swelling.  Even  then  it  is  not  easy  to  diagnose 
them  from  salivary  tumours  which  have  undergone  cystic  degenera- 
tion ;  the  only  reliable  method  being  to  withdraw  a  portion  of  the 
contents  with  an  aspirating  syringe,  and  subject  it  to  a  micro- 
scopical examination. 

Treatment. — If  the  cyst  is  situated  in  the  submaxillary  gland, 
it  is  best  to  enucleate  the  gland  entirely.  In  the  case  of  the  parotid, 
attempts  should  be  made  to  obliterate  the  cyst  by  periodic  injections 
of  tincture  of  iodine  or  of  a  concentrated  solution  of  carbolic  acid. 
But  if  these  fail,  as  they  often  do,  it  is  justifiable  to  undertake  an 
operation  for  the  excision  of  the  cyst. 

Ranula 

Ranula  is  considered  by  some  authorities  to  be  a  retention  cyst 
of  the  subUngual  gland  or  of  one  of  the  ducts  of  Rivini,  and  a  short 
account  of  it  will  therefore  be  given  at  this  point. 

A  ranula  is  a  cystic  swelling  in  the  floor  of  the  mouth,  to  one  or 
other  side  of  the  frsenum.  It  may  extend  across  the  middle  line, 
and  is  then  constricted  by  the  frsenum  lingua?.  Several  observers 
have  reported  a  bilateral  ranula,  but  this  condition  must  be  regarded 
as  one  of  great  rarity. 

It  presents  as  a  rounded,  bluish-grey,  translucent,  fluctuating 
swelling,  with  vessels  of  the  mucous  membrane  stretched  over  it.  It 
contains  a  slimy,  colourless  material  like  the  white  of  egg.  It  causes 
no   svmptoms   other    than    the    inconvenience    due    to    the   presence 


SALIVARY-GLAND   TUMOURS 

of    an   abnormal   Bwelling   in   the  mouth,   which   may  interfere   w 
mastication  and   render  articulation   imperfect. 

The  etiology  of  a  ranula  is  much  disputed.  According  to 
von  Bippel,  i1  is  a  sublingual  gland  cyst,  starting  in  the  smaller  • 
oretory  ducts,  entirely  analogous  to  tin'  salivary-gland  cysts  already 
described.  Neumann  regards  it  as  an  epithelial  cysl  derived  from 
a  t n I >ii l»-  of  one  of  Bochdalek's  glands;  while  von  Recklinghausen 
inclines  to  the  view  that  it  is  a  cysl  derived  from  the  gland  of  Blandin 
and  Nuhn,  either  by  simple  retention  or  by  degeneration  of  tin-  re- 
tamed  products  of  its  secretion. 

A  dermoid  cysl  in  the  floor  of  the  mouth  may  resemble  a  ranula 
very  closely.  A  sublingual  dermoid  is  usually  adherent  to  the  mandible 
or  to  the  hvoid  bone,  and  this  is  tin1  only  point  on  which  reliance  can 
be  placed  in  the  differential  diagnosis. 

Treatment.  —  The  only  really  efficient  treatment  is  to  dissect 
out  the  cyst  entirely  after  incising  the  overlying  mucous  membrane.  If 
this  is  not  possible,  the  next  best  method  is  to  cut  away  the  whole  of  the 
anterior  wall  and  to  allow  the  cavity  so  formed  to  cicatrize  up  slowly. 

Some  authorities  advise  removing  a  ranula  through  a  submental 
incision,  especially  if  the  cyst  is  a  big  one  and  projects  downwards 
and  forwards  towards  the  mylo-hyoid.  But  there  is  little  advantage 
in  this.  The  exposure  afforded  is  no  better  than  that  obtained  by 
the  intrabuccal  method  ;  and,  from  an  aesthetic  point  of  view,  a  scar 
in  the  mylo-hyoid  region  should  always  be  avoided  if  possible. 

TUMOURS   OF   THE   SALIVARY   GLANDS 

Tumours  of  the  salivary  glands  may  be  classified  as  follows  : — 

A.  Tumours  of  epithelial  origin — 

Innocent  :     Adenoma. 

Malignant :  Carcinoma  (a)  Adeno-carcinoma. 
(b)  Scirrhus. 

B.  Tumours  of  connective-tissue  origin — 

Innocent :    Angioma. 

Fibroma. 

Chondroma. 

Lipoma. 
Malignant:  (1)  Pure  sarcoma — 

(a)  Round-celled. 

(b)  Spindle-celled. 

(c)  Melanotic  (Billroth  and  Kaufmann). 
(2)  Mixed  sarcoma — 

(a)  Chondro-sarcoma. 

(b)  Fibro-sarcoma. 

(c)  Myxo-sarcoma. 

(rf)  Angio-sarconia  or  perithelioma. 

C.  Mixed  tumours. 


^43  THE   SALIVARY   GLANDS 

A.  Tumours  of  Epithelial  Origin 

A  pure  adenoma  of  the  salivary  glands  is  so  rare  (Nasse  has 
reported  four  cases)  that  it  demands  only  passing  mention.  It  grows 
slowly,  and  on  section  resembles  the  normal  structure  of  the  gland 
atypically  arranged.  It  is  possible  that  several  of  the  cases  described 
as  hypertrophy  of  the  parotid  were  in  reality  adenomas. 

Carcinoma  attacks  the  salivary  glands,  usually  the  parotid, 
in  two  forms,  the  medullary  or  adeno-carcinoma,  and  the  scirrhus. 
Adeno-carcinoma  may  occur  at  any  age,  but  generally  does  so  in 
early  adult  life.  A  rapidly  growing  tumour  develops.  It  is  firm  and 
elastic  in  consistence.  Ulceration  of  the  overlying  skin  and  subsequent 
fungation  are  common  features  if  the  condition  is  allowed  to  progress. 
Facial  paralysis,  of  varying  degrees,  is  usual,  according  to  whether 
the  main  trunk  of  the  nerve  or  some  of  its  branches  are  involved. 
Scirrhus  in  this  region  is  closely  analogous  to  the  mammary  form. 
It  attacks  elderly  patients,  grows  slowly,  forms  a  densely  hard  tumour, 
and  the  overlying  skin  soon  becomes  fixed  to  the  growth  and  puckered. 
Metastatic  deposits  are  found  in  the  lymphatic  glands  in  both  varieties. 
The  sublingual  gland  may  also  be  the  seat  of  carcinoma.  In  fact, 
some  authorities  believe  that  all  carcinomas  of  the  floor  of  the  mouth 
are  derived  from  this  source.  The  prognosis  with  regard  to  life  is 
bad  in  either  case,  but  worse  in  the  medullary  form.  The  diagnosis 
can  only  be  made  with  certainty  by  removing  a  portion  of  the  growth 
and  subjecting  it  to  microscopical  examination. 

As  soon  as  the  diagnosis  is  certain,  no  time  should  be  lost  in  enu- 
cleating the  affected  gland  completely,  if  this  is  still  feasible.  It  can 
rarely  be  done  if  the  surface  is  already  ulcerated.  In  this  case  the 
outlook  is  very  bad  indeed,  but  improvement  is  sometimes  produced  by 
the  application  of  X-rays  or  of  radium,  or  by  zinc  ionization. 

B.  Tumours  of  Connective-Tissue  Origin 

The  innocent  tumours  of  this  class  are  exceedingly  rare.  Clinically, 
their  characteristics  do  not  differ  from  those  presented  when  they  occur 
in  other  parts  of  the  body.  An  accurate  diagnosis  is  rarely  arrived 
at  before  the  tumour  is  removed  and  examined  histologically. 

Sarcoma. — Many  forms  of  sarcoma  have  been  described,  as  the 
table  of  classification  shows.  Pure  sarcomas,  whether  round-  or 
spindle-celled,  form  rapidly  growing  ill-defined  tumours  which  are 
difficult  to  distinguish  from  subacute  inflammation.  The  mixed  forms, 
particularly  the  fibro-sarcomas/are  more  often  encapsuled  and  present 
as  localized  swellings,  which  can  be  enucleated  in  their  capsule  from 
their  surroundings.  It  is  said  that  if  this  is  done  completely  they 
do  not  tend  to  recur.     I  am  sceptical  of  the  truth  of  this  statement. 


MIXED   TUMOURS 

Melanotic  sarcoma  of  the  parotid  has  been  described  by  E£auimann 
and    Billroth.     The  pigment  is  said   to  be  excessive.     It   is  difficult 

to  understand  whence  it   is  derived. 

When  the  presence  of  Barcoma  has  been  diagnosed,  the  affected 
gland  should  be  removed  in  its  entirety.  A  libro-sarcoma  may,  how- 
ever, be  shelled  out  with  its  capsule,  as  has  already  been  said.  It 
should  be  noted  that  the  true  sarcomatous  nature  of  these  tumours 
has  been  called  in  question.  Coley  has  reported  a  cure  of  a  small 
round-celled  sarcoma  of  the  parotid  by  the  injection  of  his  fluid  [Ann, 
tun/.,  Philadelphia,  1902). 

C.  Mixed  Tumours 

This  class  of  tumour,  of  which  specimens  are  shown  in  Figs.  343 
and  344,  is  the  most  interesting  from  the  pathological,  as  well  as  the 
most  important  from  the  clinical  point  of  view,  since  it  is  the 
commonest  neoplastic  affection  of  the  salivary  glands. 

A  mixed  tumour  forms  a  localized  well-defined  outgrowth  from  the 
gland.  The  direction  of  its  greatest  prominence  will  depend  upon 
the  portion  of  the  gland  from  which  it  takes  origin.  In  the  parotid 
this  is  usually  the  anterior  inferior  angle,  and  the  growth  tends  to 
extend  down  into  the  neck.  Occasionally  the  growth  starts  on  the 
deep  aspect,  and  it  will  then  extend  inwards  towards  the  pharyngeal 
wall.  In  the  submaxillary  gland  it  usually  springs  from  its  superficial 
surface,  and  forms  a  swelling  in  the  submental  region.  The  sublingual 
gland  is  rarely  if  ever  attacked. 

As  a  rule,  these  tumours  occur  in  middle  life.  Preceding  inflam- 
mation or  injury  is  said  to  dispose  to  them.  Their  form  is  as  variable 
as  their  consistence,  and  depends  upon  the  relative  amount  of  the 
several  connective-tissue  elements  contained.  Most  often  they  are 
firm,  rounded  or  ovoid,  and  irregular  on  the  surface.  They  are  movable 
on  the  deep  structures,  if  they  spring  from  the  superficial  aspect  of 
the  gland,  and  the  overlying  skin  is  not  attached  to  them.  If  left, 
they  tend  to  enlarge  progressively  ;  but  they  are  not  malignant  in  the 
true  sense  of  the  word — that  is,  they  do  not  endanger  the  life  of  their 
possessor,  do  not  cause  metastasis,  and  do  not  recur  if  completely 
removed. 

Mixed  tumours  cause  few  symptoms,  unless  they  are  allowed 
to  grow  to  a  great  size.  They  may  then  be  painful,  and  facial  paralysis 
may  be  observed.  In  the  case  of  parotid  tumours,  deafness  due  to 
occlusion  of  the  external  auditory  meatus  may  be  noticed.  Excess 
of  salivary  secretion  is  more  common  than  diminution.  One  curious 
feature  with  regard  to  their  growth  must  be  mentioned.  Often,  after 
slowly  increasing  in  size  for  years,  they  suddenly  enlarge  rapidly, 
and  many  patients  then  seek  advice  for  the  first  time.     This  is  an 


25o  THE   SALIVARY   GLANDS 

indication  that  the   tumour    has   taken  on   the  true    characteristics 
of  malignancy,  and  the  prognosis  is  then  correspondingly  grave. 

The  histological  appearances  of  mixed  tumours  are 
exceedingly  variable.  Their  name  is  derived  from  the  fact  that  on 
microscopical  examination  both  epithelial  and  connective-tissue  ele- 
ments are  seen.     Representatives  of  various  types  of  connective  tissue 


Fig.  343. — Mixed  tumour  of  the  parotid  gland. 

are  found,  particularly  fibrous,  myxomatous,  and  cartilaginous,  and 
epithelial  cells  are  seen  arranged  in  columns  or  in  groups.  Some 
of  these  show  a  tendency  to  cell-nest  formation,  others  to  colloid 
degeneration.  Much  discussion  has  taken  place  as  to  the  origin  of 
these  cells.  Ribbert  holds  that  they  are  genuine  epithelial  cells, 
derived  from  the  normal  cells  of  the  gland.  He  supports  his  argument 
by  the  assertion  that  prickle  processes  can  be  demonstrated  between 
adjacent  cells  and  that  the  separate  groups  are  bounded  by  a  membrana 
propria.  Volkmann  and  others  assert  that  the  cells  cannot  be  shown 
to  resemble  any  definite  epithelial  type,  and  that  they  must  therefore 


MIXED   TL'MOI  !<S 


251 


be  regarded  as  of  endothelial   origin.     Mosl    pathologi 
that  tin-  coinit'ctivr-tissui'  rli-nn'iits  arc  derived  from  errors oi  develop- 
ment; thus,   the  cartilage  comes   from    displaced    remnants   0 
bronchial  arches  or  of  the  cartilages  of   bhe  ear.     Bui    Ribberl    has 
also   described   a   special   mixed    tumour  of  the   submaxillary   gland 
which   lie  calls  a  cylindroma.     He  says  thai    is   this   both  epithelial 


Fig.  344. — Mixed  tumour  of  the  submaxillary  gland. 

and  connective-tissue  elements  are  derived  from  the  original  structure 
of  the  gland  itself. 

The  diagnosis  of  these  tumours  is  not  easy.  Reliance  cannot 
be  placed  on  any  one  sign  alone  ;  it  is,  however,  safe  to  assume  that 
any  hard,  irregular,  movable  tumour  in  the  region  of  one  of  the  salivary 
glands  which  has  persisted  for  some  time  is  probably  a  mixed  tumour. 
The  diagnosis  can  only  be  clinched  with  the  aid  of  the  microscope. 

Treatment.  —  This  consists  in  removing  the  tumour  at  the 
earliest  possible  opportunity.  It  is  said  that  a  mixed  parotid  tumour 
can  be  shelled  out,  and  that  if  this  is  done  completely  there  is  little, 
if  anv,  chance  of  recurrence.     This,  however,  is  not  the  experience  of 


252  THE   SALIVARY   GLANDS 

all  surgeons.  Butlin,  in  an  interesting  paper  in  the  Lancet  (1904), 
admitted  that  recurrence  had  taken  place  in  several  cases  in  which  he 
thought  he  had  completely  removed  the  primary  growth.  Further, 
the  recurrent  tumour  was  in  nearly  all  cases  more  rapidly  growing 
than  the  primary  one.  The  probable  explanation  is  that  an  apparently 
complete  enucleation  is  rarely  so  in  fact.  Processes  of  the  growth, 
so  small  as  to  be  inappreciable  to  the  finger,  invade  the  capsule,  and 
are  left  behind.  Under  the  influence  of  the  altered  tissue  tension 
resulting  from  the  operation,  they  take  on  a  new  and  rapid  growth, 
and,  when  seen  on  a  subsequent  occasion,  are  often  found  to  be  in- 
operable. It  is  therefore  essential  in  all  cases  to  remove  the  whole 
capsule  with  the  growth.  In  view  of  these  facts  it  would  seem  reason- 
able to  remove  the  entire  submaxillary  gland  when  this  is  the  situation 
of  a  mixed  tumour. 

When  enucleating  a  parotid  tumour,  care  must,  of  course,  be  taken 
not  to  injure  the  facial  nerve.  It  is  better  not  to  search  directly  for 
the  nerve,  but  merely  to  avoid  wounding  any  branches  which  happen 
to  become  exposed  during  the  operation. 

Operative  technique. — Mention  has  been  made  in  connexion 
with  malignant  tumours  of  complete  removal  of  the  parotid  and  sub- 
maxillary glands.  A  brief  account  of  the  technique  of  these  operations 
will  therefore  be  added. 

The  parotid  is  best  exposed  by  a  T-shaped  incision,  the  vertical 
part  extending  from  an  inch  above  the  zygoma  down  directly  in  front 
of  the  tragus  to  a  point  an  inch  below  the  angle  of  the  jaw.  A  second 
incision  is  made  extending  forwards  from  this  at  right  angles  about 
half  an  inch  below  the  zygoma.  Two  flaps  of  skin  can  thus  be  dissected 
up,  and  the  gland  exposed.  The  external  carotid  artery  should  be 
found  at  the  bottom  of  the  wound  and  divided  between  two  ligatures. 
No  hard-and-fast  rule  can  be  laid  down  about  the  actual  enucleation 
of  the  gland,  but  it  is  generally  best  to  begin  below  and  work  upwards. 
The  greatest  difficulty  will  be  experienced  in  removing  the  posterior 
deep  part  which  extends  down  to  the  spine  of  the  sphenoid.  If  all 
vessels  are  tied  as  they  are  met,  and  the  field  of  operation  thus  kept 
bloodless,  the  gland  can  nearly  always  be  removed  entire  by  the  exercise 
of  patience  and  care.  The  facial  nerve  must  of  necessity  be  sacrificed. 
The  lymphatic  glands  which  drain  the  parotid  should,  if  possible, 
be  taken  away  at  the  same  operation. 

The  extirpation  of  the  submaxillary  gland  is  a  more  simple 
procedure.  An  incision  is  made  parallel  to  and  below  the  mandible, 
curving  slightly  downwards  in  the  centre.  After  exposing  the  gland 
the  facial  artery  should  be  sought  for  at  its  lower  border,  and  tied 
between  two  ligatures.  When  this  is  done,  the  gland  can  be  enucleated 
without  danger  or  difficulty. 


THE   OESOPHAGUS 

By   H.   M.   RIGBV,    M.S.Lond.,   F.R.G.S.Enc;. 

Anatomy. — The  oesophagus  extends  from  the  lower  border  of  the 
cricoid  cartilage  to  the  cardiac  end  of  the  stomach.  Its  upper 
extremity  (Quain)  is  opposite  the  disc  between  the  sixth  and  seventh 
cervical  vertebra?.  In  its  course  downwards  it  follows  a  somewhat 
sinuous  direction,  and  has  two  distinct  curves  to  the  left  side.  The 
first  curve  to  the  left  extends  from  its  origin  to  the  root  of  the  neck. 
As  the  superior  mediastinum  is  reached,  the  oesophagus  rends  to 
in  the  mid-line,  which  it  attains  in  the  posterior  mediastinum 
about  the  level  of  the  fifth  dorsal  vertebra.  From  this  point  it  again 
deviates  to  the  left  side.  It  passes  through  a  special  opening  in  the 
diaphragm,  and  ends  in  the  stomach  opposite  the  lower  border  of 
the  tenth  dorsal  vertebra.     Its  length  is  9—10  in. 

It  is  especially  prone  to  disease  in  three  portions.     These  are — 

1.  The  upper  end.  in  the  region  of  the  cricoid  cartilage  and  larynx, 
one  of  the  narrowest  parts  of  the  oesophagus.  It  is  situated  opp<- 
the  seventh  cervical  vertebra,  and  is,  in  the  adult.  6—7  in.  from  the 
incisor  teeth.  This  is  a  very  frequent  site  of  growths  and  ulcerations. 
The  oesophagus  is  much  flattened  antero-posteriorly  in  this  part 
owing  to  the  close  apposition  of  the  cartilage  of  the  larynx  and 
the  vertebra?. 

2.  That  part  of  the  oesophagus  in  the  neighbourhood  of  the  bifur- 
cation of  the  trachea,  and  in  close  relation  with  the  left  bronchus. 
The  trachea  bifurcates  just  above  the  body  of  the  fifth  dorsal  vertebra, 
and  the  left  bronchus  crosses  in  front  of  the  oesophagus  at  the  level 
of  this  vertebra,  i.e.  about  11  in.  from  the  incisor  teeth.  This  part 
of  the  oesophagus  is  also  a  favourite  position  for  malignant  growths. 
Its  close  relation  to  such  structures  as  the  trachea,  aorta,  pleura1,  and 
pericardium  lends  additional  importance  to  the  occurrence  of  growths 
in  this  situation. 

3.  The  lower  end.   at    its  junction   with    the  stomach,    15—16   in. 
from  the  incisor  teeth.     Here  the  lumen  of  the  oesophagus  mule:  _ 
marked  narrowing,  and  the  structure  of  its  mucous  lining  manii 

253 


254  THE   (ESOPHAGUS 

an  abrupt  change  into  that  of  the  stomach.     This  is  again  a  favourite 
position  for  stricture  from  ulcer  or  malignant  growths. 

According  to  Bryant,  the  average  diameter  of  the  oesophagus  is 
I  in.,  but  at  its  commencement  the  diameter  is  h  in.  The  transverse 
exceeds  the  antero-posterior  diameter.  In  the  dead  subject  the 
lumen  is  small  and  the  mucous  membrane  thrown  into  folds.  The 
appearances  as  seen  in  life  are  very  different.  Viewed  with  the 
oesophagoscope,  the  oesophagus  is  an  open  tube,  its  lumen  enlarging 
and  diminishing  with  each  respiratorv  movement. 

Anatomical  relations  in  the  neck. — The  deep  situation 
of  the  oesophagus  in  the  neck  renders  its  exposure  difficult.  Its  most 
important  relations,  laterally,  are  the  carotid  artery  and  jugular  veins. 
The  posterior  surface  of  the  left  lateral  lobe  of  the  thyroid  is  in 
relation  with  its  anterior  surface.  The  left  recurrent  laryngeal  nerve 
has  close  relation  to  its  wall.  The  trachea  lies  directly  in  front,  the 
vertebrae,  prevertebral  muscles,  and  fasciae  behind. 

Operation  for  exposure  in  the  neck  (Fig.  345). — The 
oesophagus  can  be  satisfactorily  exposed  by  an  incision  along  the 
anterior  margin  of  the  sterno-mastoid  muscle  on  the  left  side,  low 
down  in  the  neck.  The  great  vessels  are  identified  and  drawn  out- 
wards with  the  sterno-mastoid  muscle.  The  trachea  and  left  lateral 
lobe  of  the  thyroid  are  displaced  inwards.  The  superior  and  middle 
thyroid  veins  are  divided  or  avoided.  The  inferior  thyroid  artery 
and  recurrent  laryngeal  nerve  should  be  avoided.  The  oesophageal 
wall  will  then  be  exposed  after  a  little  blunt  dissection. 

Anatomical  relations  in  the  thorax — The  oesophagus 
traverses  the  superior  and  posterior  mediastina.  It  is  situated  imme- 
diately behind  the  lower  part  of  the  trachea  and  the  left  bronchus, 
the  latter  structure  crossing  it  from  right  to  left.  It  then  lies  in  close 
relation  to  the  posterior  surface  of  the  pericardium  and  the  diaphragm. 
It  passes  through  a  special  aperture  in  the  diaphragm,  and  enters  the 
cardiac  end  of  the  stomach  about  1|-  in.  below  this  opening. 

It  has  close  relation  with  both  pleurae.  The  arch  of  the  aorta 
crosses  in  front  of  it  from  right  to  left.  The  descending  thoracic 
aorta  first  lies  to  its  left  side  and  then  passes  behind  it,  and  finally 
reaches  its  right  side  at  a  point  3  in.  above  the  diaphragm. 

Behind  the  oesophagus  are  the  vertebral  column  and  left  longus  colli 
muscle  ;  the  thoracic  duct  in  the  superior  mediastinum ;  the  vertebral 
portions  of  the  right  intercostal  arteries  and  the  vena  azygos  minor. 

The  vagus  nerves  have  close  relation  to  its  wall,  forming  the 
"  plexus  gulae." 

Operation  for  exposure  in  the  thorax. — The  oesophagus 
may  be  exposed  in  the  thoracic  part  of  its  course  by  removing  portions 
of  the  ribs  between  the  angles  and  the  transverse  processes  of  the 


Ml. TIIODS   OK    EXAMINATION 


-55 


corresponding  vertebra.     Portions  of  three   ribs  are  divided,   and   a 
flap  composed  of  the  bones  and  sofl  parts  is  raised  up.     This  operation 

posterior  mediastinal  thoracotomy     baa  I a  described  and  practised 


Fig.  345. — Structures  exposed  in  the  operation  of  cervical 
cesophagotomy. 

by  Bryant.     The  position  at  which  the  operation  is  carried  out  depends 
on  the  site  of  the  lesion  in  the  oesophagus. 

METHODS    OF    EXAMINATION" 
1.  Inspection  and  palpation. — These  can  only  be  of  value 
when  the  cervical    portion  of    the  oesophagus  is  affected.      Tumours 


256 


THE   (ESOPHAGUS 


of  the  wall  may  reveal  a  swelling  to  the  left  side  of  the  trachea.  A 
pouch  may  form  an  easily  recognizable  tumour.  Enlarged  glands 
Becono&sy  to  oesophageal  disease  may  be  present. 

2.  Percussion. — This  method  is  seldom  of  assistance.  A  large 
pouch  in  the  neck  may  give  rise  to  a  tympanitic  note,  or  a  greatly 
dilated  oesophagus  may  possibly  occasion  altered  resonance  over  the 

posterior  thoracic  wall. 

3.  Auscultation.  —  By  the  em- 
ployment of  the  stethoscope,  certain 
sounds  may  be  heard  over  the  oesophagus 
during  and  after  the  act  of  swallowing. 
These  sounds  are  due  (1)  to  deglutition, 
(2)   to    food   entering  the   stomach.     In 

(disease  of  the  wall,  especially  when  a 
stricture  has  occurred,  the  interval  be- 
tween the  two  sounds  is  increased  after 
swallowing  fluids.  An  obstruction  to  the 
passage  of  food  can  thus  be  inferred  from 
auscultation,  but  this  method  of  examina- 
tion is  uncertain  and  of  little  practical 
value. 

4.  Examination  by  bougies. — 
By  this  method  any  obstruction  can  be 
located,  and  its  extent  and  permeability 
determined. 

As  a  preliminary  the  presence  of 
aneurysm  must  be  carefully  excluded. 
for  the  sac  of  an  aneurysm  pressing  on 
the  oesophageal  wall  might  be  penetrated 
by  the  injudicious  use  of  a  bougie. 

Again,  in  advanced  carcinoma  of  the 
oesophagus  the  instrument  must  be  care- 
fully passed  ;  otherwise  the  ulcerated  wall 
may  be  perforated  or  violent  hsemorihau"- 
excited  by  the  point  of  the  bougie. 

With  these  exception.^,  bougie  exam- 
ination becomes  a  matter  of  routine 
in  cases  01  dysphagia.  The  instruments  used  are  generally  solid 
flexible  cylindrical  or  oval  bougies,  which  are  either  conical  in 
shape  or  have  a  bulbous  end.  They  are  composed  of  silk  web  or 
elastic  gum,  and  are  easily  malleable  when  warmed.  They  are  usually 
22  in.  in  length,  and  vary  in  size  from  Xo.  7  to  Xo.  21,  English 
catheter  gauge.     (See  Fig.   346.) 

The  introduction  of  an  oesophageal  bougie  is  a  simple  procedure, 


) 


Fig.  346. — Bougies  for  ex- 
amination of  oesophagus. 

A,    Bougie    with   metal   acorn    t 
graduated  conical  bougie  ;  c,  i>,  cylin- 
drical bougies ;    E,  conical  bougie ;    F, 
bulbous-ended  bougie. 


EXAMINATION   OF   THE   (ESOPHAGUS 

though  at  firsl  decidedly  unpleasant  to  the  patient.  When  the  larynx 
[a  reached,  violenl  expiratory  efforts  with  a  closed  glo  generally 

excited,  often  followed  by  retching  as  the  stomach  is  entered.  How- 
ever, tolerance  is  surprisingly  soon  established  by  custom. 

In  passing  a  bougie  the  Burgeon  should  stand  facing  the  patient. 
The  instrument  should  be  dipped  into  a  basin  of  warm  water,  lubri- 
cated with  oil  or  vaseline,  and  curved  so  as  to  pass  easily  over  the 
base  of  the  tongue.  The  patient  is  then  directed  to  extend  the  neck 
and  open  the  mouth.  A  gag  is  unnecessary,  and  any  introduction 
of  ringers  or  instruments  to  depress  the  tongue  should  be  avoided, 
inasmuch  as  it  only  excites  retching  and  additional  discomfort.  The 
point  of  the  bougie  is  now  pushed  over  the  dorsum  of  the  tongue  and 
gently  on  down  the  posterior  pharyngeal  wall,  past  the  region  of  the 
larynx,  where  it  is  generally  arrested  by  spasm  of  the  inferior  con- 
st rid  or  and  the  narrowness  of  this  part  of  the  oesophagus.  With 
slight  gentle  pressure  forwards,  the  point  then  enters  and  passes  down 
the  oesophagus  to  the  site  of  the  obstruction.  Any  further  mani- 
pulations must  now  be  carried  out  with  gentleness.  If  the  wall  of 
the  oesophagus  is  ulcerated,  considerable  pain  may  be  caused  by  the 
contact  of  the  bougie.  Haemorrhage  may  occur,  and  even  perforation 
of  the  wall  has  resulted  from  violent  efforts  to  overcome  an  obstruction. 
If  the  bougie  will  not  readily  pass,  smaller  ones  should  be  tried.  Should 
the  obstruction  prove  impassable,  the  further  methods  of  examination 
to  be  presently  described  should  be  employed.  If  there  be  a  stricture 
through  which  a  bougie  can  be  made  to  pass,  its  extent  and  diameter 
can  be  estimated  by  means  of  a  bougie  with  an  acorn-shaped  extremity 
(Fig.  346,  a). 

5.  X-ray  examination. — This  method  depends  upon  the  intro- 
duction of  certain  substances  which  are  known  to  be  impervious  to 
the  X-rays.  Sounds  containing  metallic  cores  of  lead  or  mercury  are 
passed  down  the  oesophagus  and  held  in  position  while  the  X-rays 
are  passed  through  the  thorax  and  focused  on  a  screen.  More  fre- 
quently, in  the  place  of  sounds,  certain  preparations  of  bismuth  or 
iron  are  administered  by  the  mouth.  Bismuth  oxychloride,  subnitrate, 
or  oxide  is  given  in  the  form  of  a  cachet  or  suppository  paste,  or 
in  suspension.  For  this  purpose  the  oxychloride  is  preferable  to  the 
subnitrate. 

This  method  of  examination  is  very  valuable  in  the  recognition 
of  strictures  and  pouches  of  the  oesophagus. 

The  patient  is  made  to  stand  or  sit  with  the  arms  raised  and  the 
hands  resting  on  the  top  of  the  head.  The  thorax  is  so  placed  that 
the  rays  traverse  it  in  the  oblique  direction,  usually  from  right  to  left. 
By  this  means  the  shadows  formed  by  the  vertebral  column  and  heart 
and    great  vessels  are  avoided.     The  rays  are   focused    on  a  screen 


THE   (ESOPHAGUS 


placed  behind  the  patient,  who  is  directed  to  swallow  the  prepared 
bismuth  ;  the  shadow  formed  by  this  substance  as  it  passes  down 
the  oesophagus  can  be  easily  seen.  If  a  stricture  be  present,  the 
bismuth  collects  at  its  site  and  may  form  a  dark  mass  of  considerable 
size  which  reproduces  the  shape  of  the  oesophagus  at  the  site  of  the 
constriction.     If  the  existence  of  a  pouch  be  suspected  the  patient 

is  directed  to  take 
some  bread  -  and  - 
milk  or  mashed 
potatoes  with  which 
the  bismuth  salts 
are  mixed.1 

6.  Direct  ex- 
amination—  By 
the  employment  of 
the  cesophagoscope 
a  direct  examina- 
tion of  the  interior 
of  the  oesophagus 
can  be  undertaken. 
Foreign  bodies  can 
be  seen,  and  their 
nature,  shape,  and 
position  be  de- 
termined ;  morbid 
growths  and  ulcer- 
ations can  also  be 
investigated.  The 
instrument  devised 
by  Killian  and 
modified  by  Briin- 
ing  has  many  ad- 
van  t  a  g  e  s.  Its 
essential  parts  are 
shown  in  Fig.  347. 
The  important 
features  of  this  in- 
strument are  the  ingenious  method  of  illumination  and  the  ease  with 
which  an  instrument  can  be  manipulated  within  the  tube. 

(Esophagoscopy  may  be  performed  under  either  local  or  general 
anaesthesia.     As  a  rule  it  is  far  better  to  employ  ageneral  anaesthetic  ; 
the  examination  may  take  some  time,  and  the  necessarily  constrained 
position,  with  the  head  extended,  is. very  trying  to  the  patient. 
>  See  also  Vol.  I.,  p.  648. 


Fig.  347. — Instruments  used  in  oesophagoscopy. 

A,   Briining's  electroscope  with  oesophageal  tube  ;  B,  extending  oeso- 
phageal tube ;    c,  elastic  gum  obturator  ;  D,  oesophagus  forceps. 


(ESOPHAGEAL    MALFORMATIONS  259 

The  patient  may  be  placed  in  the  following  positions  during  the 
passage  of  the  instrument,  viz.  :  (1)  Sitting  on  a  stool  with  the  neck 
extended  and  head  thrown  well  back;  (2)  recumbent  with  the  head 
hanging  well  down  over  the  end  of  the  operating  table;  (3)  lying  on 
the  Bide  with  the  neck  again  fully  extended. 

The  tube  is  to  be  warmed  and  oiled  ;  it  may  then  be  introduced 
with  a  pilot  bougie  inserted  through  its  lumen,  but  it  is  far  safer  and 
more  satisfactory  to  pass  the  instrument  by  direct  vision  with  the 
illuminating  apparatus  attached.  This  method  obviates  therisk  of  per- 
forating an  ulcer  just  below  the  cricoid,  or  of  pushing  on  an  impacted 
foreign  body  ;  it  also  permits  the  examination  of  the  pharynx  during 
the  passage  of  the  tube. 

AVhile  the  patient's  head  is  held  well  extended  by  an  assistant, 
the  surgeon  with  his  left  hand  passes  the  tube  over  the  dorsum  of 
the  tongue  until  he  sees  the  posterior  pharyngeal  wall ;  he  then  tilts 
the  handle  upwards  and  continues  the  introduction  until  the  upward 
movement  is  checked  by  the  upper  incisor  teeth.  The  assistant  now 
slightly  inclines  the  head  towards  the  left  shoulder,  without  rotating 
or  tilting  the  neck,  and  the  surgeon  slips  the  tube  into  the  right  angle 
of  the  mouth  and  passes  it  onwards  down  the  oesophagus.  The  whole 
manoeuvre  is  carried  out  by  direct  vision  through  the  tube. 

MALFORMATIONS 

The  following  rare  malformations  may  occur  (Whipham  and 
Fagge)  :— 

Congenital  absence  of  the  entire  oesophagus. 

Bifurcation  of  the  oesophagus  with  union  of  the  two  divisions 

towards  the  lower  end. 
Congenital   atresia,    often   associated   with   cesophago-tracheal 

fistula. 
Pressure  pouches. 
Strictures  due  to  the  pressure  of  a  valve-like  fold  of  mucous 

membrane. 
Congenital  stenosis  of  the  lower  end  of  the  oesophagus. 
Only  two  of  these  conditions  need  be  considered  here,  viz.  con- 
genital atresia  and  congenital  stenosis. 

Congenital  Atresia.    Tracheoesophageal  Fistula 
This  malformation  has  more  of  a  developmental  than  a  surgical 
interest,  and  little  can  be  done  to  remedy  it. 

Loss  of  continuity  of  the  oesophagus  with  the  pharynx,  in  these 
cases,  occurs  near  the  lower  end  of  the  trachea.  There  is  normally 
a  narrowing  of  the  oesophagus  about  2f  in.  below  its  origin,  marking 
the  origin  of  the  pulmonary  diverticulum.     In  congenital  atresia  the 


260  THE   (ESOPHAGUS 

pharynx  and  upper  end  of  the  oesophagus  terminate  blindly  just  above 
this  region,  while  the  oesophagus  ends  above  bv  opening  into  either 
the  trachea  or  one  of  the  bronchi. 

Keith  and  Spicer  show  that  the  trachea  and  bronchi  are  de- 
rived directly  from  the  foregut  through  subdivision  of  the  channel 
by  the  tracheo- oesophageal  septum.  The  fistula  formed  betwe?n  the 
oesophagus  and  trachea  in  the  above-mentioned  deformity  is  the 
result  of  failure  in  union  of  the  lateral  ridges  which  unite  to  form 
this  septum. 

Shattock  points  out  that  this  does  not  depend  on  a  failure  of  com- 
munication between  the  stomodaeum  and  the  anterior  blind  end  of  the 
mesenteron,  as  the  pharynx  is  itself  developed  from  the  mesenteron. 
He  suggests  that  the  atresia  is  a  secondary  process  due  to  kinking 
of  the  wall  of  the  mesenteron  during  the  development  of  the  lower 
part  of  the  trachea  and  lungs. 

In  rare  cases  the  upper  part  of  the  canal  communicates  with  the 
trachea.  The  lower  portion  may  end  blindly  above  without  com- 
munication with  the  air-passages,  or  it  may  be  simply  represented 
by  a  fibrous  cord.  The  two  portions  may  be  connected  by  a  narrow 
fibrous  cord  (Lotheissen). 

The  symptoms  produced  by  this  deformity  are  those  of  complete 
oesophageal  obstruction  ;  all  food  taken  is  immediately  vomited,  and 
the  infant  rapidly  dies  of  inanition. 

The  condition  can  be  diagnosed  by  the  passage  of  a  bougie.  The 
only  possible  treatment  is  gastrostomy,  with  a  view  to  dealing  with 
the  obstruction  later.  The  prognosis,  however,  is  generally  quite 
hopeless  (Keith  and  Spicer). 

Strictures  due  to  a  valve-like  folding  of  the  mucous  membrane 
occur  either  just  below  the  pharynx  or  near  the  lower  end  of  the 
oesophagus. 

Stenosis  of  the  Lower  End  of  the  (Esophagus 
Whipham  and  Fagge  record  a  case  of  tubular  fibrous  stricture 
of  the  lower  end  of  the  oesophagus  in  a  girl  of  4|-  years.     They  could 
only  find  records  of  six  similar  cases. 

DIVERTICULA 1 

Diverticula  of  the  oesophagus  occur  :  (1)  At  or  about  the  junction 
of  the  pharynx  with  the  oesophagus  ;  (2)  in  the  middle  third  of  the 
oesophagus  in  close  relation  with  the  bifurcation  of  the  trachea  and 
left  bronchus  ;  (3)  in  the  lower  part  of  the  oesophagus  above  the 
diaphragm. 

1  This  account  of  the  condition  is  largely  based  on  an  excellent  paper  by 
Halsted. 


PRESSURE   DIVERTICULA  261 

From  an  etiological  point  of  view  these  pouches  are  classified  as 
follows  : — 

1.  Pressure  diverticula. 

2.  Tract  ion  diverticula. 

3.  Traction-pressure  diverticula. 

According  to  Halsted  they  occur  in  the  following  situations,  viz. 
(a)  in  the  pharynx  ;  (6)  at  Ihe  pharyngo-oesophageal  junction;  (c)  at 
the  upper  margin  of  the  left  bronchus  (epibronchial)  ;  (d)  just  above 
the  diaphragm  (epiphrenic). 

1.  Pressure  Diverticula 

The  commonest  and  most  interesting  are  those  found  at  the  junction 
of  the  oesophagus  and  pharynx.  They  give  rise  to  flask-shaped  pouches 
communicating  with  the  lower  end  of  the  pharynx  by  a  narrow  opening 
which  has  a  constant  position  on  the  posterior  pharyngeal  wall  at  the 
lower  border  of  the  inferior  constrictor  muscle.  Like  other  diverticula 
in  the  alimentary  canal,  they  really  consist  of  herniated  pouches  of 
mucous  membrane  protruding  between  the  fasciculi  of  the  muscular 
wall.  The  muscle  fibres  generally  end  more  or  less  abruptly  at  the 
neck  of  the  sac,  and  the  main  part  of  the  Avail  of  the  pouch  is  com- 
posed of  mucous  membrane  covered  with  an  envelope  of  thickened 
fibrous  connective  tissue.  As  this  pouch  enlarges  it  takes  the  path 
of  least  resistance,  and  therefore  tends  to  protrude  on  either  side  of 
the  oesophagus,  more  commonly  the  left.  It  may  extend  gradually 
downwards,  and  its  neck  become  so  elongated  that  the  fundus  of  the 
sac  reaches  the  mediastinum.  It  may  give  rise  to  a  well-marked 
swelling  in  the  posterior  triangle  of  the  neck.  The  gradual  enlargement 
of  the  pouch  is  due  to  food  being  forced  into  its  interior  from  above 
by  the  contraction  of  the  constrictor  muscle  of  the  pharynx. 

The  etiology  of  these  diverticula  has  been  much  discussed.  They 
are  said  to  be  congenital,  but  there  is  no  actual  proof  of  this  statement. 
At  the  lower  border  of  the  pharynx,  where  it  joins  with  the  oesophagus, 
there  is  said  to  be  a  natural  deficiency  of  muscular  support,  the  so- 
called  "  Lannier  "  triangle  (Mayo). 

Probably,  as  Keith  suggests,  they  are  generally  produced  as  follows  : 
In  the  act  of  deglutition  the  bolus  of  food  is  rapidly  thrown  to  the 
lower  and  narrowest  part  of  the  pharynx,  when  it  is  immediately 
grasped  and  driven  downwards  by  the  forcible  contraction  of  the  lower 
constrictor  muscles.  The  food  is  squeezed  between  the  broad  resisting 
base  of  the  cricoid  in  front  and  the  upper  end  of  the  oesophagus  behind. 
The  posterior  part  naturally  presents  a  weak  resistance,  owing  to  the 
peculiar  arrangement  of  its  muscle  fibres,  and  so  a  small  protrusion 
may  readily  occur.  A  slight  protrusion,  once  formed,  can  be  easily 
enlarged  by  intake  of  food  at  each  act  of  deglutition. 


262 


THE   (ESOPHAGUS 


There  are  undoubtedly  other  explanations  for  this  condition,  as 
Halsted  points  out.  Injury  to  the  oesophageal  wall  in  this  region  has  been 
followed  by  pouch  formations,  and  the  association  of  congenital  stricture 
of  the  upper  part  of  the  oesophagus  with  a  diverticulum  has  been  re- 
corded. {See  Fig.  348.) 

Pressure  diverticula 
generally  occur  in  elderly 
male  patients.  They  often 
give  a  history  of  long- 
standing dysphagia,  and 
the  first  symptoms  are 
merely  those  indicative 
of  stenosis  of  the  oeso- 
phagus, for  a  long  period 
unaccompanied  by  loss 
of  weight  or  deteriora- 
tion in  health.  Later 
the  following  symptoms 
arise :  If  solid  food  be 
taken,  a  feeling  of  dis- 
comfort and  pressure  is 
experienced  in  the  neck, 
as  if  a  foreign  body  were 
present.  Eegurgitations 
of  portions  of  food  occur 
sometimes  shortly  after 
eating,  but  occasionally 
at  long  intervals,  even 
twelve  hours  after  a 
meal.  Ejection  of  gas 
may  accompany  the  eva- 
cuation of  the  food  by 
the  mouth.  The  food  is 
undigested,  and  not  at 
all  suggestive  of  stomach 
contents  ;  and  when  the 
pouch  gets  filled,  further 
passage  of  food  clown 
the  oesophagus  may  be 
completely  arrested.  The  oesophagus  becomes  pushed  to  one  side, 
and  the  pouch  comes  to  lie  more  directly  in  a  line  with  the  lower 
part  of  the  pharynx.  Pressure  on  the  filled  pouch  in  the  neck  may 
be  followed  by  rejection  of  some  portion  of  the  contained  food.  The 
spitting  up  of  quantities  of  mucus  has  been  noticed  in  one  case. 


Fig.   348. — Pressure   diverticulum   at 
pharyngo -oesophageal  junction. 

i,   Neck  of  pouch  ;   2,  oesophagus  ;   3,  pouch. 
(Royal  College  0/  Surgeons  Museum.) 


(ESOPHAGEAL    DIVERTICULA  263 

Examination  of  the  neok  may  reveal  a  swelling  on  the  lefl 
below  the  cricoid  cartilage,  but  this  sign  ia  often  absent.    It  is  said 
to  be  presenl  in  one-third  of  the  cases  reported. 

It'  a  bougie  be  passed  il  generally  enters  the  pouch,  and,  ii  made 

of  metal,  its  point  may  he  felt  in  the  posterior  triangle  of  the  neck. 
The  simultaneous  passage  of  two  bougies,  one  of  which  enters  the 
pouch  and  the  other  the  stomach,  is  sometimes  possible. 

The  presence  of  a  pouch  has  in  several  cases  been  clearly  illustrated 
by  X-ray  examination  after  the  administration  of  a  bismuth  meal. 
A  pouch  filled  with  this  throws  a  dense  shadow  on  the  screen  and 
clearly  demonstrates  its  outline. 

The  double  opening  should  be  easily  seen  by  the  use  of  the  oeso- 
phagoscope. 

Mayo  refers  to  a  method  of  diagnosis  employed  by  Plummer.  A 
silk  thread  is  swallowed  in  sufficient  quantities  to  pass  through  the 
stomach  into  the  intestine.  A  bulbous-ended  oesophagus  probe  is 
threaded  on  the  silk  and  passed  down.  When  it  can  be  passed  no 
farther,  the  string  is  tightened.  If  a  diverticulum  be  present,  the 
bulbous  end  is  pulled  upwards  to  the  mouth  of  the  diverticulum.  If 
a  stricture  only  be  present,  the  position  of  the  probe  is  not  altered. 

2.  Traction  Diverticula 

These  are  of  less  surgical  importance,  as  they  generally  remain 
of  small  size  and  may  not  give  rise  to  any  symptoms.  They  usually 
occur  in  the  middle  and  lower  portion  of  the  oesophagus.  As  their 
name  implies,  they  are  generally  caused  by  traction  on  the  oesophagus 
wall  (Rokitansky).  This  may  be  due  to  inflammation  of  glands  or 
to  fibrous  contraction  following  inflammation  in  the  peri-cesophageal 
tissues. 

The  structure  of  the  wall  of  the  pouch  is  similar  to  that 
of  a  pressure  diverticulum.  The  diverticulum  is  horizontal,  or  the 
opening  may  be  on  a  lower  level  than  the  pouch  itself :  hence  food 
rarely  tends  to  collect,  and  results  of  pressure  do  not  occur. 

The  pouches  are  situated  on  the  anterior  wall  of  the  oesophagus, 
just  below  the  bifurcation  of  the  trachea  (Fig.  349). 

The  chief  danger  associated  with  traction  diverticula  is  the  pos- 
sibility of  perforation  of  their  wall  by  foreign  bodies,  leading  to 
haemorrhage  or  mediastinal  infection.  Fistulous  communication  with 
the  air-passages  has  also  been  noted. 

3.  Traction-Pressure  Diverticula 

These  are  formed  as  the  result  of  the  passage  of  food  into  traction 
diverticula.  They  are  rarely  encountered,  for  the  reasons  giveD 
above. 


!04 


THE   (ESOPHAGUS 


Treatment  of  diverticula. — The   treatment  of    oesophageal 
pouches  consists  in  their  removal  by  dissection,  with  closure  of  the 

neck  by  suture.1 

After  a  prelimi- 
nary cleansing  of  the 
patient's  mouth,  the 
pouch  is  emptied, 
then  exposed  by  an 
incision  along  the 
anterior  margin  of 
the  sterno  -  mastoid 
muscle,  and  dissected 
out  with  the  least 
possible  disturbance 
of  the  surrounding 
tissues.  It  may  be 
either  cut  away  and 
its  neck  secured  by 
tiers  of  sutures,  or 
it  may,  if  small,  be 
in  raginated  into  the 
oesophagus.  The 
chief  iisk  is  subse- 
quent leakage  and 
formation  of  a  fis- 
tula. Free  drainage 
should  always  be 
employed,  and  rectal 
feeding  administered 
for  the  first  three 
days  after  operation. 
The  fistula,  if  it 
occurs,  tends  to  close 
naturally  in  a  few 
weeks.  This  opera- 
tion is  not  accom- 
panied by  much 
shock,  and  it  has 
been  successfully 
performed  in  elderly 
patients. 


Fig.  349. — Traction  diverticulum  on  the  an- 
terior surface  below  the  bifurcation  of  the 
trachea. 

(London  Hospital  Pathological  Department.') 


1  The  operation  is  well  described  in  Jacobson*s  "  Operations  of  Surgery," 
and  full  reference  is  there  given  to  Butlin's  and  Maurice  Richardson's  well-known 
papers  on  the  subject. 


(ESOPHAGEAL   RUPTURE 

Tho  results  of  operative  treatment   in  ,n  case*  have  been  tabulated  bj 

Dervil  Stetten   as  follows  : 

i)t  go  oases,  50  were  cured  and  10  died,  a  mortality  of  lot;  per  cent, 
Of  48  oases  in  which  the  sac  was  excised  withoul  preliminary  gastrostomy, 
8  ended  in  death,  a  mortality  of  18*7  per  cent. 

Of  .">  oases  in  which  a  preliminary  gastrostomy  bad  been  performed,  l 

ended  fatally,  a  mortality  of  -"  per  cent. 

All  tli.-  patients  operated  on  by  the  other  methods  recovered  In  4  cases 
invagination  of  the  sac  was  employed.  In  -  tho  sac  was  excised  in  two 
.  and  in  1  case  the  mucosa  of  the  sac  was  destroyed. 

Primary  union  of  the  oesophagus  wound  occurred  in  21  of  tin-  50  cases 
that  recovered.     In  the  others  leakage  occurred. 

No  recurrences  were  reported. 

RUPTURE 

Rupture  of  the  rrsopliagu.s  has  resulted  from  over-distension  of 
its  wall,  previously  weakened  by  disease.  In  a  few  cases  in  which  a 
rupture  was  found  post  mortem,  no  evidence  of  disease  was  present. 

Bowles  and  Turner  describe  the  case  of  a  woman  aged  02,  in  whom 
rupture  of  the  oesophagus  occurred  after  a  severe  attack  of  vomiting. 
West,  Andrews.  "Williams,  and  others  have  noted  similar  cases. 

Rupture  of  the  oesophagus  may  be  a  result  of  severe  injuries  to 
the  thorax  or  upper  abdomen.  In  the  absence  of  disease  or  injury 
a  rupture  is  an  extremely  rare  event ;  I  could  only  find  one  doubtful 
case  in  the  pathological  records  of  the  London  Hospital  duiing  the 
last  twenty  years. 

It  has  been  suggested  that  some  degenerative  change  in  the 
oesophageal  wall,  so-called  "  cesophago-malacia,"  precedes,  and  may 
be  the  direct  cause  of,  the  rupture. 

Rolleston  points  out  that  simple  ulceration  and  rupture  are 
generally  found  in  the  lower  part  of  the  oesophagus.  In  all  the 
recorded  cases  the  rupture  appears  to  have  been  situated  in  the 
neighbourhood  of  the  cardiac  end.  The  tear  is  longitudinal,  generally 
of  small  extent,  from  -J  to  1  in.  in  length,  and  is  complete,  so  that 
the  oesophageal  contents  can  escape  into  the  posterior  mediastinum. 
The  accident  appears  to  be  more  common  in  males  than  in  females. 
Possibly  chronic  alcoholism  may  be  a  predisposing  factor. 

The  symptoms  generally  occurred  in  association  with  or  imme- 
diately after  a  severe  attack  of  vomiting.  Extreme  pain  referred  to 
the  lower  part  of  the  thorax,  both  back  and  front,  was  usually  present. 
In  some  of  the  cases  ha?matemesis  followed,  but  generally  vomiting 
ceased  after  the  rupture.  Attempts  to  swallow  were  followed  by 
severe  pain  referred  to  the  lower  part  of  the  thorax.  The  pulse  was 
either  slow  and  tense,  owing  to  irritation  of  the  vagi,  or  small  and 
quick  if  much  shock  was  present.  In  the  early  stage  no  definite 
physical  signs  were  noted  ;  later  the  implication  of  the  mediastinum 


266  THE   (ESOPHAGUS 

or  pleura  gave  rise  to  signs  of  spreading  suppuration  in  the  neck  or 
thorax. 

Subcutaneous  emphysema  was  noted  in  some  of  the  cases  re- 
ported. 

Diagnosis  has  always  been  most  difficult ;  it  must  be  well- 
nigh  impossible,  indeed,  in  the  absence  of  previous  history  pointing 
to  disease  of  the  oesophagus. 

Surgical  treatment  by  exposing  the  oesophagus  through  the 
posterior  mediastinum  appears  to  be  the  only  possible  course  to 
adopt.  The  diagnostic  difficulty  and  the  rapidly  fatal  termination 
of  these  cases  account  for  the  absence  of  surgical  intervention  up  to 
the  present  time. 

INJURIES 

The  oesophagus,  on  account  of  its  protected  position,  is  not  fre- 
quently injured.  Its  wall  may,  however,  be  penetrated  from  without 
or  from  within,  in  either  the  cervical  or  the  thoracic  portion  of  its 
course. 

1.  Injuries  from  Without 

(a)  Wounds  of  the  cervical  portion  are  more  common,  and  include 
incised  and  stab  wounds  and  injuries  by  a  bullet. 

The  oesophagus  is  not  usually  injured  in  self-inflicted  wounds  of 
the  neck.  These  are  generally  placed  obliquely  at  the  upper  part 
of  the  neck,  and  open  the  pharynx  above  the  thyroid  cartilage.  The 
rare  cases  of  incised  wounds  of  the  oesophagus  are  generally  com- 
plicated by  extensive  injury  to  the  trachea. 

Stab  wounds  of  the  neck  may  penetrate  the  oesophagus  with  but 
little  injury  to  the  surrounding  parts. 

Bullet  wounds  of  the  oesophagus  in  the  neck  generally  inflict 
severe  injury  on  the  surrounding  structures. 

The  oesophagus  has  been  wounded  in  rough  attempts  to  perform 
tracheotomy,  and  in  the  performance  of  surgical  operations  such  as 
thyroidectomy  (Berry).1 

(b)  Wounds  of  the  thoracic  'portion  are  uncommon.  They  are 
generally  caused  by  stab  or  gunshot  wounds.  Penetration  of  the 
oesophagus  here  generally  implies  injury  to  the  thoracic  viscera,  and 
is  most  dangerous  owing  to  the  certain  risk  of  infection  of  the  sur- 
rounding tissues,  mediastina,  pleura,  or  pericardium. 

2.  Injuries  from  Within 

These  include  wounds  of  the  wall  inflicted  by  the  passage  of  foreign 
bodies,  bougies  or  other  instruments.     If  a  pathological  condition  of 
the  wall  is  present  or  ulceration  has  occurred,  penetration  may  be 
1  "Diseases  of  the  Thyroid  Gland,"  p.  304. 


FOREIGN   BODIES  2G7 

the  result  of  but  slight   violence.     The  infliction  of  damage  duiin_- 
the  passage  of  bougies  to  relieve  a  stricture  is  not  uncommon. 

The  oesophagus  has  been  wounded  by  '*  sword  swalloweis." 

Symptoms  and  signs  of  injury. — The  symptoms  of  oesopha- 
geal wounds  may  be  masked  by  those  of  injury  to  the  surroundiii'_r 
structures. 

Dysphagia  accompanied  by  vomiting  of  blood  suggests  implication 
of  the  oesophagus  ;    attempts  to  swallow  may  cause  severe  pain.     If 
there   is  an  external  wound  the  presence  of  food  or  saliva  in  I 
discharge  points  to  a  wound  of  the  oesophageal  wall.     In  the  cervical 
portion  the  diagnosis  is  generally  obvious. 

Treatment. —  If  possible,  an  attempt  should  be  made  to 
suture  the  wound  in  the  wall  of  the  oesophagus.  Free  drainage 
is  essential. 

FOREIGN    BODIES 

In  children  the  objects  most  frequently  swallowed  by  accident 
are  metal  toys,  pins,  and  coins.  In  adults,  bones  of  meat  or  fish,  and 
other  constituents  of  food  too  hastily  swallowed,  may  lodge ;  or  an 
ill-fitting  tooth-plate,  especially  when  worn  at  night,  is  very  liable 
to  become  detached  and  slip  down  the  oesophagus  (Figs.  350,  352). 

A  proportion  of  these  foreign  bodies  pass  down  the  oesophagus 
into  the  stomach,  and  are  voided  in  the  faeces  without  causing  trouble. 
Impaction  of  a  foreign  body  in  the  oesophagus  is  always  a  source  of 
great  danger.  Those  with  sharp  or  jagged  edges  are  very  liable  to 
cause  ulceration  or  even  penetration  of  the  oesophageal  wall.  Decom- 
position of  retained  particles  of  food  as  a  result  of  the  obstruction 
is  an  additional  source  of  danger. 

Foreign  bodies  tend  to  lodge  opposite  the  three  narrow  portions 
of  the  oesophagus.  By  far  the  commonest  site,  however,  is  the  upper 
part,  between  the  cricoid  cartilage  and  the  tracheal  bifurcation. 
Fortunately,  foreign  bodies  seldom  become  impacted  in  the  lower  half 
of  the  oesophagus,  though  this  may  occur  if  they  have  been  pushed 
down  by  instruments  used  for  their  extraction.  In  children,  foreign 
bodies  generally  lodge  about  the  level  of  the  episternal  notch.  In 
hospital  practice  the  impaction  of  coins  at  this  level  is  a  matter  of 
common  occurrence. 

The  symptoms  produced  vary  considerably.  Unless  secondary 
complications  arise,  but  little  discomfort  may  be  present.  The  severity 
of  the  symptoms  is  determined  by  the  site  of  the  impaction  and 
the  shape  and  position  of  the  foreign  body. 

If  it  be  impacted  at  the  upper  part  of  the  oesophagus,  the  larynx 
may  be  irritated  or  actually  compressed  so  that  urgent  dyspnoeic 
svmptoms  are  excited.     But  if,  as  is  usually  the  case,  the  foreign  body 


258 


THE   (ESOPHAGUS 


be  fixed  near  the  upper  end  but  below  the  cricoid,  then  respiratory 
symptoms  are  absent.  There  is  more  or  less  dysphagia,  and  generally 
solid  food  cannot  be  swallowed.  Occasionally  the  oesophagus  is  so 
completely  obstructed  that  even  fluids  are  regurgitated  ;  on  the  other 
hand,  in  certain  cases,  semi-solid  food  can  be  swallowed  with  ease. 
Constant  vomiting  may  be  excited  by  the  lodgment  of  a  foreign  body 
in  the  upper  part  of  the  oesophagus.     This  was  present  in  a  case  under 

my  care.  In  another 
case  the  impaction  of 
a  tooth-plate  in  the 
cervical  portion  of 
the  oesophagus  (Fig. 
350)  gave  rise  to  se- 
vere pain  even  when 
saliva  was  swallowed. 
Pain  referred  to  the 
sternum  in  front,  or 
between  the  scapulae 
posteriorly,  may  be 
caused  by  impaction 
of  a  foreign  body  in 
the  lower  part  of  the 
oesophagus. 

When  ulceration 
has  occurred,  vomit- 
ing of  mucus  streaked 
with  blood  may  be 
present. 

Foreign     bodies 
may  remain    lodged  in    the    oesophagus    for    years    and   cause   but 
little   trouble.      They  may,  however,  soon  after  impaction,  occasion 
complications  accompanied  by  symptoms  of  great  urgency. 
The  secondary  complications  are — 

1.  Ulceration  of  the  oesophageal  wall  at  the  site  of  impaction; 

2.  Formation  of  a  submucous  abscess. 

3.  Perforation  of  the  wall  of  the  oesophagus. 

4.  Peri- oesophageal  inflammation  and  suppuration  in  the  neck  or 
thorax. 

5.  Erosion  of  the  trachea  or  bronchi,  with  formation  of  fistulas. 

6.  Perforation  of  large  vessels. 

7.  Inflammation  or  suppuration  in  the  pleurae  or  pericardium. 

8.  Formation  of  a  cicatricial  stricture  due  to  ulceration. 

The  symptoms  caused  by  these  complications  are  those  either  of 
haemorrhage  or  of  septic  involvement  of  the  neck  or  mediastina.- 


Fig.  350. — Tooth  plate  removed  by  the  author 
by  cervical  cesophagotomy.  It  had  lodged 
opposite  the  seventh  cervical  vertebra. 


FOREIGN    BODIES  269 

Perforation  of  the  oesophageal  wall  causes  severe  pain,  accom- 
panied by  risr  of  temperature  and  general  malaise.  Cervical  emphy- 
sema generally  ensues  later.  When  a  large  vessel  is  involved,  hemor- 
rhage may  be  slight  al  first  ;  it  is  recurrent,  generally  ingravescent, 
and  a  final  severe  bleeding  may  bring  about  a  fatal  issue. 

Perforation  of  the  aorta  by  impacted  coins  and  other  foreign  bodies 
led  to  a  fatal  issue  from  haemorrhage  in  live  cases  recently  reported 
by  Turner. 

Involvement  of  the  air-passages,  pleura?,  etc.,  gives  rise  to  charai  - 
teristic  signs  and  symptoms. 

Diagnosis. — In  most  cases  the  diagnosis  of  the  presence  of  a 
foreign  body  impacted  in  the  oesophagus  is  a  matter  of  no  great 
difficulty.  A  history  of  the  swallowing  of  the  article  in  question  is 
often  obtainable,"  but  in  the  case  of  children  this  may  be  entirely 
absent.  Sudden  onset  of  dysphagia  in  a  child  without  another  cause 
is  suggestive  of  the  presence  of  a  foreign  body,  and  routine  examina- 
tion as  a  rule  clears  up  the  diagnosis. 

In  children  the  first  step,  whenever  possible,  is  to  make  an  examina- 
tion by  the  X-rays.  It  is  not  advisable  to  start  the  examination  by 
the  passage  of  bougies,  as  this  requires  a  general  anaesthetic,  and  may 
do  harm  by  displacing  the  foreign  body  downwards.  If  the  X-ray 
examination  reveals  a  shadow  it  will,  as  before  stated,  generally  be 
situated  near  the  upper  border  of  the  sternum.  The  position  and 
size  of  the  body  can  by  this  means,  as  a  rule,  be  determined  with 
accuracy.  Occasionally  a  coin,  if  impacted  in  the  upper  part  of  the 
oesophagus,  can  be  palpated  in  the  neck. 

In  adults  it  is  also  advisable  to  employ  the  X-rays  as  the  pre- 
liminary step  in  the  examination.  As  a  general  rule,  foreign  bodies 
can  easily  be  detected  in  the  oesophagus  of  an  adult  by  this  means. 
The  rays  must  be  caused  to  pass  obliquely  through  the  patient, 
especially  if  impaction  has  occurred  low  down,  to  avoid  the  shadow 
caused  by  the  vertebrae,  heart,  and  great  vessels.  Metallic  bodies 
are  generally  recognized  with  ease,  but  small  portions  of  vulcanite 
tooth-plates  with  teeth  attached  may  form  so  faint  a  shadow  that 
their  detection  is  a  matter  of  great  difficulty.  In  these  cases  it  is  a 
good  plan  to  administer  bismuth  emulsion,  which  adheres  to  the 
plate.  The  radiograph  plate  should  be  examined  in  the  wet  state, 
immediately  after  its  development. 

When  X-rays  are  not  available,  a  bougie,  preferably  a  flexible 
one  with  a  cylindrical  metal  tip,  should  be  passed  down.  The  presence 
of  a  foreign  body  and  the  site  of  impaction  are  then  determined. 

The  cesophagoscope  is  invaluable  for  the  detection  and  direct 
examination  of  foreign  bodies  in  the  oesophagus.  It  is  advisable 
always  to  examine  with  this  instrument    under  general    anaesthesia, 


27o  THE   (ESOPHAGUS 

therefore  its  employment^  better  deferred  until  attempts  at  extraction 
have  been  decided  upon.  In  one  case,  where  a  small  tooth-plate 
was  impacted  at  the  lower  part  of  the  oesophagus,  I  was  able 
through  an  cesophagoscope  tube  to  move  it  from  its  position  and 
push  it  down  into  the  stomach.  In  other  cases,  removal  through  or 
with  the  tube  may  be  possible. 

Treatment. — The  methods  employed  for  the  removal  of  foreign 
bodies  from  the  oesophagus  are  as  follows  : — 

1.  Displacement  downwards  into  the  stomach  by  means  of 

bougies. 

2.  Extraction  by  means  of  instruments  through  the  mouth. 

3.  Extraction  by  means  of  instruments  through  an  opening 

made  in  the  oesophagus  or  stomach. 

1.  Displacement  downwards  should  only  be  attempted  in  the 
case  of  smooth  bodies,  and  sometimes  when  impaction  takes  place  in 
the  lower  part  of  the  tube. 

2.  In  the  majority  of  cases,  extraction  by  means  of  instru- 
ments through  the  mouth  is  the  method  of  choice,  and  is 
generally  practicable.  Incision  of  the  oesophagus  or  stomach  should 
only  be  considered  when  this  has  failed.  The  fact  that  most  foreign 
bodies  tend  to  become  impacted  in  the  upper  part  of  the  oesophagus 
facilitates  their  removal  by  the  mouth. 

In  children,  instrumental  treatment  should  always  be  carried  out 
under  an  anaesthetic.  In  adults  this  is  not  always  necessary.  If 
the  foreign  body  be  a  small  one,  such  as  a  pin,  fish-bone,  etc.,  it  may 
be  extracted  by  means  of  the  well-known  expanding  probang  of 
Fergusson,  or  by  means  of  forceps  (Fig.  351,  a,  b,  c,  f). 

If  the  patient  be  a  child,  and  a  coin  or  other  article  be  impacted 
in  the  upper  part  of  the  oesophagus,  attempts  at  extraction  are  made. 
An  anaesthetic  is  given,  and  the  instrument  passed  down  through 
the  mouth.  Coins  can  generally  be  removed  by  means  of  a  coin- 
catcher  or  forceps,  preferably  the  former  (Fig.  351,  D,  e).  This  instru- 
ment is  composed  of  steel,  and  the  handle  and  stem  should  be 
made  in  one  piece.  At  the  extremity  a  ring  of  steel,  bent  at  its 
middle  to  an  acute  angle,  is  soldered  to  the  stem.  The  ring  should 
not  be  hinged,  but  securely  fastened  to  the  stem.  Many  accidents 
have  happened  as  the  result  of  faulty  construction  of  this  instrument. 

I  always  employ  the  X-rays  during  the  introduction  of  the  coin- 
catcher.  The  child  is  placed  flat  on  the  back  on  a  couch  beneath 
which  the  X-ray  lamp  is  placed.  The  coin-catcher  is  gently  passed 
down  the  oesophagus  until  an  obstruction  is  felt ;  the  room  is  then 
darkened  and  the  X-ray  light  switched  on,  a  hand-screen  being  placed 
over  the  front  of  the  neck  and  thorax.  The  end  of  the  coin-catcher 
and  its  relation  to  the  foreign  body  can  be  clearly  seen,  and  further 


EXTRACTION   OF    FOREIGN    BODIES 


271 


manipulations  can  be  performed  with  exactness.  If,  however,  as 
must  often  happen,  the  X-rays  are  not  available,  the  coin-catcher 
is  passed  under  anaesthesia,  and  the  coin  can  generally  be  extracted 


?f 


Fig.  351. — Instruments  used  in  removing  foreign  bodies  from  the 

oesophagus. 

j*.  (Esophageal  forceps;  b,  c,  laryngeal  forceps;  d,  e,  coin-catchers;  f,  Ferguson's  probang. 


272  THE   (ESOPHAGUS 

without  much  difficulty.  The  end  of  the  instrument  must  be  passed 
with  great  gentleness  until  below  the  foreign  body,  and  then  pulled 
upwards.  When  the  coin  reaches  the  narrow  portion  at  the  cricoid 
a  hitch  is  generally  felt,  but  with  a  little  manoeuvring  this  can  be 
overcome.  If  the  foreign  body  be  of  angular  shape,  the  coin-catcher 
is  not  of  much  use,  and  various  forceps  (Fig.  351,  a,  b,  c)  should  be 
used  for  the  extraction.  The  use  of  X-rays  is  invaluable,  again,  for 
this  latter  procedure. 

Treatment  for  an  adult  should  be  conducted  on  the  same  lines. 

If  careful  attempts  at  extraction  have  failed  by  these  means,  and 
the  foreign  body  is  firmly  impacted  owing  to  its  irregular  shape  or 
sharp  edges,  it  may  be  possible  to  alter  its  position,  or  even  to 
extract  it,  by  means  of  the  cesophagoscope.  Von  Hacker  considers 
that  extraction  by  means  of  this  instrument  is  generally  practicable. 
It  is  hardly  possible  to  extract  any  but  small  bodies  through  the 
largest  tube  of  this  instrument,  but  it  is  an  easy  matter  to  grasp 
them  with  forceps  introduced  through  the  tube,  or  even  to  cut 
them  up  with  an  instrument  suitable  for  the  purpose. 

3.  Extraction  through  an  incision  in  the  wall  of  the 
oesophagus. — The  indications  for  this  are — ■ 

i.  When  the  foreign  body  cannot  be  displaced  and  extracted 
through  the  mouth. 

ii.  When  evidence  of  ulceration  of  the  wall  of  the  oesophagus  is 
present. 

iii.  When  symptoms  of  perforation  of  the  waJl  of  the  oesophagus 
are  present. 

iv.  When  complications,  such  as  haemorrhage  or  septic  infection 
of  the  surrounding  tissues  or  thoracic  viscera,  have  supervened. 

Cervical  cesophagotomy  is  indicated,  as  a  rule,  for  the  removal  of 
sharp,  jagged  bodies,  such  as  a  tooth-plate,  impacted  in  the  upper 
part  of  the  oesophagus.  It  is  possible  by  this  means  to  remove,  by 
the  introduction  of  suitable  forceps,  a  body  situated  as  low  down  as 
the  position  of  the  bronchi  (Bennet  May).  On  one  occasion  I  removed 
a  tooth-plate  which  was  impacted  opposite  the  3rd  dorsal  vertebra 
(Fig.  352). 

Richardson  says  that  a  length  of  oesophagus  6  in.  below  the 
cricoid  is  accessible  by  this  route.  In  certain  cases  it  is  necessary 
to  cut  up  the  foreign  body  to  facilitate  its  extraction.  In  the  case 
of  a  toy  bicycle  impacted  in  the  oesophagus,  and  removed  by  me, 
this  manoeuvre  had  to  be  carried  out  before  extraction  was  possible 
(Plate  89).  This  procedure  was  also  necessary  in  a  case  recorded 
by  Lawson. 

The  operation  of  cervical  cesophagotomy  is  not  difficult,  but  is 
attended  with  some  danger  owing  to  the  risk  of  septic  infection  of 


nm 


Toy   bicycle    impacted    in    the    oesophagus.      Removed    by    the    author 

by  cervical  cesophagotomy.     The    machine    had    to    be    cut    in    two    by 

forceps  before  extraction  was  possible. 


Plate  S9. 


REMOVAL   ()K    FOREIGN    BODIES 


273 


thf  tissue  planes  in  the  neck.  The  dissection  to  expose  the  oesophagus 
should  be  made  with  accuracy,  and  with  as  little  tearing  ol  the  tissues 
as  possible.  The  opening  made  in  the  u'sopha^us  wall  can  usually 
be  closed  by  absorbable  sutures,  and  Eree  drainage  must  be  permitted  ; 
in  fact,  the  wound  may  be  entirely  left  open  for  this  purpose.  In 
most  cases  a  fistula  occurs  and  persists  for  a  short  time,  especially  if 
ulceration  be  present,  but,  as  a  rule,  it  closes  spontaneously:  Rectal 
feeding  is  advisable 
for  three  days  after 
this  operation. 

If  the  foreign  body 
be  impacted  in  the 
oesophagus  at  its  lowei 
part,  it  may  be  ex- 
tracted from  below- 
after  gastrotomy.  Ac- 
cording to  Richardson, 
3  in.  of  the  lower  end 
of  the  oesophagus  is 
accessible  for  this  pur- 
pose. 

The  most  difficult 
problem  to  deal  with 
is  impaction  of  a  body 
in  that  part  of  the 
oesophagus  inaccessible 
from  above  or  from 
below.  For  these  diffi- 
cult cases,  Bryant  has 

devised  and  carried  out  the  operation  of  mediastinal  cesophagotomy. 
He  approaches  the  oesophagus  from  the  right  side,  in  the  case  of  a 
foreign  body  situated  below  the  aortic  arch,  by  resecting  portions  of 
three  ribs  close  to  the  spine.  The  posterior  mediastinum  is  opened 
up  and  the  oesophagus  incised.  In  this  operation  there  is  great  risk 
of  infection,  and  it  has  seldom  been  carried  out  in  this  country. 
Fortunately,  impaction  of  a  foreign  body  rare.y  takes  place  in  that 
portion  of  the  oesophagus  which  is  inaccessible  from  above  or  below. 
It  may  be  possible,  by  means  of  forceps  introduced  through  the  tube 
of  an  cesophagoscope,  as  in  a  case  mentioned  above,  to  displace  a 
body  impacted  in  this  position  downwards  until  it  comes  within 
reach  of  the  cardiac  orifice. 

Gastrotomy  is  indicated  for  the  removal  of  bodies  situated  13  in.  or 
more  below  the  incisor  teeth.  The  stomach  is  opened  and  attempts  are 
made  to  dilate  the  cardiac  orifice  by  the  finger  or  a  suitable  instrument. 


Fig.  352. — Tooth-plate  removed  by  the  author 
by  cervical  cesophagotomy.  It  had  lodged 
opposite  the  3rd  dorsal  vertebra. 


274  THE   (ESOPHAGUS 

Careful  traction  of  the  stomach  downwards  with  flexion  of  the  spine 
renders  the  cardiac  orifice  easier  of  access  (Bryant). 

Mortality  of  cesophagotomy  for  foreign  bodies. — Tillman 
quotes  G.  Fischer — in  108  cases  a  mortality  of  20  per  cent. — and 
EglofE — in   135  cases  a  mortality   of   24'8  per  cent. 

OBSTRUCTION 

The  conditions  which  lead  to  a  narrowing  of  the  oesophagus,  giving 
rise  to  dysphagia,  are  as  follows  : — 

I.  INTRINSIC^  originating  in  the  oesophageal  wall. 

1.  Spasm  of  the  muscle  coat.    CEsophago-spasm.    Cardio-spasm. 

Globus  hystericus. 

2.  Cicatricial  contracture,   consequent  upon  ulceration  of  the 

mucous   membrane. 

Causes — (a)  Wounds. 

(b)  Burns. 

(c)  Syphilis. 

(d)  Tuberculosis. 

(e)  Typhoid  fever. 
(/)  Peptic  ulcers. 

3.  New  growths. 

(a)  Innocent. 

(b)  Malignant. 

[I.  EXTRINSIC.     Pressure    on,    or    invasion    of,    the    wall    of    the 
oesophagus  from  without. 

1.  Aneurysms. 

2.  Tumours.     Enlarged  glands,  new  growths. 

3.  Abscess. 

I  A  Till  N  S  I  C    0  B  S  TRUCTIO  A 

Spasm  of  the  Muscle  Coat 

A  diffuse  dilatation  of  the  wall  of  the  oesophagus  associated  with 
contraction  of  the  cardiac  opening,  or  cardio-spasm,  occurs  in  young 
adults  of  both  sexes.  The  etiology  of  this  somewhat  rare  condition 
has  given  rise  to  much  discussion,  and  its  treatment  to  the  exhibition 
of  much  mechanical  ingenuity. 

Pathology. — The  specimen  of  which  Fig.  353  is  a  drawing 
shows  the  pathological  changes  usually  present.  The  muscular  coat 
of  the  entire  wall  of  the  oesophagus  is  hypertrophied,  whilst,  in  the 
lower  three-fourths  of  its  extent,  marked  dilatation  has  taken  place. 
The  mucous  coat  is  also  greatly  thickened,  and  scattered  over  its 
surface    are    numerous    shallow    ulcers.     At    the    cardiac    orifice    the 


CARDIOSPASM  275 

muscular  hypertrophy  is  most  noticeable;  the  lumen  is  here 
greatly  diminished,  and  ihc  mucous  membrane  is  thrown  into 
longitudinal  folds.  There  is,  however,  no  ulceration  Been  in  this 
part.     Such  marked  changes  are  found  in  the  chronic  forma  of  the 

disease. 

Etiology.-  It  is  doubtful  whether  a  true  primary  dilatation 
occurs  irrespectively  of  obstruction  to  the  cardiac  orifice.  In  most 
eases  the  dilatation  and  hypertrophy  are  probably  secondary  to  a 
narrowing  of  the  cardia  dependent  on  muscular  spasm,  which  may 
be  of  nervous  origin,  and  has  been  said  to  follow  emotional  dis- 
turbances (Sippey).  This  spasm  may  be  secondary  to  inflammation 
or  actual  ulceration  of  the  mucous  membrane,  but  very  often  stands 
alone.  In  a  case  reported  by  Ledderhose  it  appeared  to  be  caused 
by  the  presence  of  a  polypus.  Malignant  growths  at  the  cardia  arc 
often  associated  with  spasmodic  contraction  of  the  muscular  coat, 
but  the  obstruction  is  then  dependent  chiefly  upon  the  presence  of 
the  growth  itself. 

Cardio-spasm  is,  however,  frequently  independent  of  any  patho- 
logical change  in  the  mucous  membrane,  and  many  theories  have 
been  suggested  to  explain  this  fact.  Some  authorities  hold  that  an 
alteration  in  the  nerve  muscular  mechanism  exists.  Degeneration 
of  the  vagi  nerve  fibres  which  supply  this  part  of  the  oesophagus  has 
been  demonstrated  by  Kraus.  According  to  Kosenheim,  the  con- 
dition is  due  to  primary  action  of  the  muscle  wall,  associated  with 
disturbance  of  innervation.  Klebs  found  fatty  degeneration  of  the 
muscular  wall.  Fleimer  believes  that  the  dilatation  is  due  to  some 
developmental  anomaly.  Mikulicz,  Meltzer,  and  Leichtenstern  agree 
that  spasm  of  the  cardia  is  the  cause  of  the  dilatation,  but  are  unable 
to  explain  the  spasm. 

Young  adults  of  both  sexes  may  be  the  subjects  of  this  curious 
condition,  though  females  of  hysterical  tendencies  are,  perhaps,  more 
frequently  affected.  The  clinical  course  of  the  disease  is  suggestive 
of  a  congenital  origin. 

The  symptoms  may  be  of  long  duration,  and  the  intermittent 
form  sometimes  lasts  over  many  years.  The  onset  may  be  either 
sudden  or   gradual. 

The  most  important  symptom  is  dysphagia.  The  onset  is  some- 
times acute,  and  for  some  time  the  patient  is  quite  unable  to  swallow 
either  solids  or  fluids.  A  stage  of  remission  follows,  with  recurrence 
of  symptoms  after  a  variable  period.  The  dysphagia  due  to  mechanical 
obstruction  differs  in  that  it  is  gradual  and  progressive.  Xothnagel 
points  out  as  a  characteristic  sign  that  solid  food  may  sometimes 
pass  down  more  easily  than  liquids.  Dysphagia  is  accompanied  by 
a  feeling  of  pressure  in  the  thorax,  and  sometimes  by  burning  pains 


276  THE   (ESOPHAGUS:    INTRINSIC  OBSTRUCTION 


Fig.  353. — Diffuse  dilatation  of  the  oesophagus  with 
cardio-spasm. 

[London  Hospital  Pathological  Department.} 


radiating  to  the  neck 
and  shoulders.  Accu- 
mulation of  food  in  the 
oesophagus  gives  rise 
to  a  sense  of  fullness 
behind  the  sternum. 
These  symptoms  are 
relieved  by  effortless 
regurgitation  of  a  large 
quantity  of  undigest- 
ed food,  mixed  with 
mucus,  but  free  from 
gastric  acids  or  fer- 
ments. In  long-stand- 
ing cases,  loss  of  weight 
occurs,  and  failure  of 
the  general  health. 

In  some  cases  there 
is  no  obstruction  to  the 
passage  of  a  bougie, 
although  large  quan- 
tities of  food  or  liquid 
may  be  retained  in  the 
oesophagus. 

A  bougie,  when 
passed  down,  stops 
opposite  the  cardiac 
end  of  the 
oesophagus. 
After  a 
short  inter- 
val its  point 
may  be  felt 
to  engage  in 
the  open- 
ing and  be 
gripped  by 
the  con- 
stricting 
muscle.  It 
may  then 
be  passed 
through 
into     the 


CARDIOSPASM  277 

stomach  by  a  little  pressure.  If  tin's  happens,  the  diagnosis  of 
spasmodic    stricture    may    be   confidently    made.      More    often    the 

bougie  will  not  pass,  nor  even  engage  the  stricture.  Keen  points 
out  that  the  tube  can  be  abnormally  moved  about  in  the  dilated 
oesophagus. 

Examination  with  the  oesophagoscope  should  then  be  under- 
taken. In  the  recorded  cases  the  cardia  has  been  seen  constricted, 
and  the  mucous  membrane  heaped  up  in  longitudinal  folds  so  as  to 
give  a  rosette-like  appearance.  The  surface  of  the  mucosa  may  be 
pale,  or  intensely  red,  or  even  ulcerated. 

The  oesophageal  dilatation  can  be  demonstrated  by  the  X-rays 
on  the  fluorescent  screen  after  the  administration  of  bismuth  in  food. 
A  fusiform  shadow  is  seen  in  a  typical  case  ;  by  this  means  the  presence 
of  a  diverticulum  may  be  excluded. 

Examination  by  auscultation  shows  retardation  or  absence  of  the 
second  swallowing  sound. 

Among  other  methods  of  examination  may  be  mentioned  the  two- 
tube  test  of  Rumpel,  and  the  passage  of  a  rubber-coated  sound  con- 
nected to  a  eudiometer  as  suggested  by  Strauss. 

The  prognosis  is  unfavourable. 

Treatment  is  difficult,  and  may  only  relieve  temporarily. 
The  indications  are  to  attempt  to  overcome  the  spasm  by  means  of 
medicines  and  the  passage  of  sounds.  If  emaciation  be  present, 
hollow  sounds  for  feeding  purposes  should  be  passed  if  possible. 

The  oesophagoscope  may  assist  the  passage  of  sounds.  Rectal 
feeding  is  sometimes  necessary  in  the  acute  attacks,  whilst  for  extreme 
cases  gastrostomy  may  become  necessary.  If  dilatation  has  occurred, 
the  passage  of  bougies  gives  only  temporary  relief  (Sippey). 

Rolleston  refers  to  cases  successfully  treated  by  Sippey,  who 
employed  a  rubber-bag  dilator. 

Mikulicz  recommends  that  the  stomach  be  opened  and  the  cardia 
dilated  by  means  of  special  rubber-coated  forceps.  He  quotes  six 
successful  cases. 

Rosenheim  in  two  cases  successfully  dilated  a  cardiac  spasmodic 
stricture  by  introducing  rubber  bags  which  were  then  filled  with  air 
or  water. 

Fibrous  Stricture  of  the  (Esophagus 
Etiology. — Fibrous  cicatricial  stricture  occurs   as   a    late   result 
of  ulceration  of  the  mucous  membrane. 

This   ulceration  is   generally   due   to   the   swallowing   of   corrosive 
fluids  or  of  boiling  water,  but  occasionally  follows  the  impaction  of 
a  foreign  body,  whilst  rarely  it  is  tuberculous  or  syphilitic  in  origin. 
*  Pathology The  formation  of    the    stricture  depends    entirely 


278  THE   OESOPHAGUS 

on  the  position,  extent,  and  degree  of  the  burn  or  injury  inflicted  on 
the  wall  of  the  oesophagus. 

As  regards  position,  naturally  the  brunt  of  the  injury  falls  upon 
the  narrower  portions  of  the  tube,  viz.  (1)  at  its  origin  ;  (2)  opposite 
the  bifurcation  of  the  trachea  ;    (3)  at  the  cardiac  end. 

The  burns  may  be  sharply  localized  to  any  one  of  these  positions, 
or  may  extend  over  the  entire  wall,  causing  greater  destruction  of 
tissue  opposite  the  narrower  portions. 

The  degree  of  the  burn  and  the  amount  of  tissue  destruction 
depend  on  the  nature  of  the  fluid  and  the  rapidity  with  which  it 
enters  the  stomach. 

The  stricture  resulting  from  a  localized  burn  may  be  only  super- 
ficial, giving  rise  to  an  annular  or  linear  narrowing.  This  is  not 
common.  More  extensive  and  deep  burns  cause  considerable  tubular 
narrowing  with  marked  fibrous  thickening  of  the  entire  wall  of  the 
oesophagus.  Even  the  peri-oesophageal  tissues  are  sometimes  involved, 
and  their  contraction  may  distort  the  wall  of  the  oesophagus  and  lead 
to  a  deviation  from  its  natural  position.  The  oesophageal  Avail  above 
the  stricture  may  be  dilated  and  thinned,  but  this  is  not  often  seen. 
More  commonly  a  thickening  involving  the  muscular  and  outer  coat 
is  present  and  extends  above  and  below  the  stricture.  In  my  experi- 
ence this  is  more  commonly  seen  in  tubular  strictures.  (In  superficial 
annular  strictures  dilatation  above  the  narrowing  is  more  likely  to 
occur.) 

The  oesophagus  at  the  site  of  the  stricture,  and  above  and  below, 
is  generally  transformed  into  a  tough,  unyielding  tube  (Fig.  354). 
Progressive  contraction  of  the  cicatrized  area  gradually  occurs,  leading 
to  a  dense  and  resistant  stricture.  The  mucosa  is  usually  destroyed, 
but  the  submucous  tissue  contains  large  numbers  of  plasma  cells 
and  everywhere  shows  formation  of  new  connective  tissue.  The 
circular  muscular  fibres  are  generally  much  hypertrophied. 

Sometimes  ulceration  of  the  mucous  membrane  occurs  in  the 
dilated  wall  above  the  stricture  as  the  result  of  the  lodgment  and 
decomposition  of  retained  particles  of  food.  Pouches  of  the  wall 
very  rarely  take  place. 

The  diagnosis  of  fibrous  strictures  of  the  oesophagus  due  to 
the  action  of  a  corrosive  is  not  difficult.  The  patient  complains  of 
a  gradually  increasing  dysphagia,  commencing  at  variable  periods 
after  the  injury.  The  symptoms  immediately  following  the  burn  are 
chiefly  pain  and  inability  to  swallow  any  but  liquid  food.  This  con- 
dition improves  after  a  few  days,  when  more  and  more  solid  food 
can  be  taken.  After  a  week  or  two  the  symptoms  of  a  progressive 
dysphagia  supervene.  The  dysphagia  is  painless  and  ingravescent, 
and,  unless  treatment  be  adopted,  gradually  becomes  absolute.     The 


FIBIUHS   STK1CTURK 


279 


diagnosis  1-  confirmed)  after  the  usual  routine  examination  to  exclude 
other  causes  of  oesophageal  stenosis,  by  the  introduction  of  the 
0Bsophagos<  ope  and  t  he 
passage  oi  bougies.  Ii 
the  patienl  is  able  to 
swallow  Hauls,  a  solution 
of  bismuth  given  by  the 
mouth  and  the  employ- 
ment of  X-rays  may  gn  e 
valuable  information  as  to 
the  site  and  extenl  Lit  the 
strict  ure. 

Treatment.  1.  By 
mechanical  dilatation. 
— This  treatment  should 
be  attempted  at  first  in 
all  permeable  fibrous  stric- 
tures of  the  oesophagus. 
A  medium-sized  flexible 
gum-elastic  bougie  with 
conical  tip  is  passed  down 
the  oesophagus,  and  very 
gentle  attempts  are  made 
to  engage  its  point  in  the 
stricture.  If  any  difficulty 
is  experienced,  a  smaller- 
sized  bougie  must  be  tried. 
If  that  fails,  a  filiform 
bougie  or  catgut  whip 
should  be  used.  A  stiff 
graduated  b  o  u  g  i  e  (Fig. 
355,  b)  will  sometimes  be 
found  the  most  useful  in- 
strument in  locating  and 
engaging  the  mouth  of  the 
stricture.  The  whip  may 
be  used  alone,  or  be  di- 
rected to  th?  stricture 
through  a  hollow  bougie 
which  is  first  passed  down 
to  the  site  of  the  obstruc- 
tion. If  the  bougie  and  whip 
fail  to  enter  the  stricture,  the  cesophagoscope  should  be  passed  down 
and  attempts  made  to  see  the  opening.     If  it  be  impossible  to  find  the 


Fig.  354. — Tubular  stricture  of  the  middle 
third  of  the  oesophagus  resulting  from 
the  action  of  a  corrosive. 

{London  Hospital  Pathological  Department.) 


28o 


THE   (ESOPHAGUS 


opening  by  this  means,  or   to  pass  any  bougie,  then  further  opera- 
tive treatment  must  be  considered. 

If  a  bougie  passes  through  the  stricture,  dilatation  can  be  pro- 
ceeded with. 

Dilatation  can  be  effected 
either  (a)  by  passing  bougies 
in  gradually  increasing  sizes 
at  intervals  of  several  days 
(intermittent  dilatation),  or 
(6)  by  inserting  and  leaving 
in  position  suitable  cathe- 
ters through  which  the  pa- 
tient can  be  fed  (continuous 
dilatation). 

In  children  and  in  other 
cases  in  which  much  diffi- 
culty or  distress  is  occa- 
sioned by  the  passage  of 
the  bougie,  the  latter  me- 
thod will  be  found  most 
serviceable. 

(a)  Intermittent  dilata- 
tion.— The  bougie  is  passed 
and  left  in  position  for  a 
few  minutes  ;  a  larger  size 
is  then  introduced  and  kept 
in  for  a  similar  period ; 
this  is  removed,  and  after 
a  couple  of  days'  interval 
a  further  trial  is  made  with 
a  bougie  of  slightly  larger 
calibre.  By  this  means  gra- 
dual dilatation  is  effected. 

Special  forms  of  bougies 
have  been  invented  in  order 
to  overcome  the  difficulty 
of  gradual  dilatation.  The 
so-called  "  railway  "  bougie 
(Fig.  355,  a)  consists  of  a 
hollow  gum-elastic  bougie, 
which  is  passed  over  a  small 
solid  bougie  already  intro- 
duced through  the  stricture  as  a  guide.  By  the  successive  passage 
of  larger  ones  the  stricture  can  sometimes  be  rapidly  dilated. 


Fig.  355. — Bougies  for  dilating  the 
oesophagus. 

"  Railway"  bougie  ;  B,  graduated  bougie  ;    c,  rubber 
tulie  stretched  <>n  whalebone.    (Von  Hacker.) 


DILATATION    OF    HHKOl'S   STRICTURE 


Von  Hacker  has  invented  an  ingenious  method  "l  dilating  tight 
and  difficult  strictures.     The   instrumenl    (Kg.  355,  i  ).  consisting  oi 

a  rubbrr  drainage  tube  stretched  on  a  central  guide  of  whalebone  or 
other  still  material,  is  inserted  into  the  stricture.     When  the  guide  is 

withdrawn  the  tube  shortens  and  retracts,  with  corresponding  expan- 
sion of  its  circumference.     This  rubber  tube  is  left  in  the  stricture 
for  Borne  tunc,  and  thus  the  stricture  is  uniformly  dilated.     The  guide 
must  be  well  oiled   to  ob- 
viate    difficulty     in     with- 
drawal.    In    my  experience 
this  method  is  unsatisfactory 
tor  very  tight  strictures.    A 
straight,  rigid  guide  is  diffi- 
cult   to    introduce    and    to 
engage  in    the    opening    of 
the  stricture. 

(b)  Continuous  dilatation. 
— A  hollow  tube  with  a 
funnel-shaped  upper  end  is 
passed  down  by  means  of 
an  introducer  and  left  in 
situ.  Symonds's  well-known 
tubes  are  of  the  greatest 
value  and  the  best  for  this 
purpose  (Fig.  356,  A  to  d). 
They  are  especially  useful 
when  there  is  much  diffi- 
culty in  passing  bougies, 
and  if  the  patient  is  in 
urgent  need  of  nourishment. 
When  multiple  strictures 
are  present,  as  is  not  in- 
frequent, a  short  Symonds's 
tube  will  dilate  the  upper, 

and  perhaps  more  constricted,  portion,  and  so  permit  later  access  to 
the  lower  part  of  the  oesophagus.  These  tubes  may  be  left  in  for  a 
week  or  ten  days  at  a  time. 

In  strictures  in  the  upper  part  of  the  oesophagus  the  long,  upper, 
funnel-shaped  end  is  apt  to  irritate  the  larynx.  In  a  case  of  mine  this 
was  obviated  by  cutting  down  the  funnel.  The  tube  is  kept  in  situ  by 
silk  which  comes  out  of  the  mouth  or  nose  and  is  fixed  to  the  auricle. 
It  is  a  good  plan,  if  the  silk  is  passed  out  of  the  mouth,  to  thread 
upon  it  a  piece  of  small  rubber  drainage-tube.  This  prevents  the  possi- 
bility of  the  silk  being  bitten  through  if  an  anaesthetic  has  been  given. 


Fig.  356. — Symonds's  tubes. 

Symonds's  long  tube ;    B,   introducer  ;    c 
Symonds's  short   tubes. 


282  THE   OESOPHAGUS 

2.  Palliative  measures. — If  no  instrument  can  be  passed  through 
the  stricture,  then  a  temporary  gastrostomy  should  be  made,  to  permit 
feeding  and  to  afford  rest  to  the  oesophagus.  After  a  few  days,  further 
attempts  at  dilatation  may  be  successful.  If,  however,  after  a  suitable 
period,  bougies  cannot  be  passed  down,  the  procedure  adopted  by 
Abbe,  Dunham,  and  others  is  worth  a  trial.  This  consists  of  making 
the  patient  swallow  one  end  of  a  string  of  silk  (Dunham),  or  of  a  piece 
to  which  a  shot  has  been  attached  (Abbe).  The  silk  passes  down 
into  the  stomach,  and  is  found  and  brought  out  through  a  gastrotomy 
opening.  Abbe  employs  the  string  to  act  as  a  saw  and  so  divide  the 
constricted  portions  :  when  this  is  done  a  bougie  is  fastened  to  the 
upper  end  and  pulled  down  from  below. 

When  the  stricture  is  placed  low  down  in  the  oesophagus  it  can 
sometimes  be  dilated  from  below,  through  the  opening  in  the  stomach, 
by  the  passage  of  suitable  forceps  or  dilators,  or  even  the  finger.  Con- 
siderable difficulty  is  often  experienced  in  this  manoeuvre,  but  successful 
cases  have  been  reported  by  Kendal  Franks  and  others. 

Cutting  instruments  after  the  pattern  of  urethrotomes  have  been 
devised  for  the  division  of  impassable  oesophageal  strictures  (internal 
cesophagotomy).  These  are  always  dangerous  owing  to  the  risk  of 
their  cutting  through  the  wall  and  leading  to  mediastinal  infection. 
They  are  condemned  by  most  surgeons. 

Electrolysis  of  the  stricture  has  been .  attempted  in  a  few  cases 
(Franks),  but  the  method  has  little  value. 

Finally,  mention  may  be  made  of  operations  which  are  planned 
to  divide  the  strictures  from  without  (external  cesophagotomy),  or  even 
to  excise  the  stenosed  portion.  Such  operations  are  indicated  when 
an  impassable  stricture  of  small  extent  is  situated  in  the  upper  portion 
of  the  oesophagus. 

The  oesophagus  is  exposed  as  for  cesophagotomy,  and  the  extent 
of  the  stricture  determined.  If  possible  the  wall  is  opened  below 
the  stricture,  and  the  latter  divided  from  below  upwards  ;  bougies 
are  then  passed,  and  dilatation  effected.  The  opening  in  the  wall 
is  now  carefully  closed,  and  free  drainage  provided.  This  gives  most 
satisfactory  results,  but  unfortunately  is  seldom  practicable.  The 
stricture  is  often  found  to  extend  into  the  thorax,  so  that  the  incision 
has  to  be  made  either  directly  over  the  stenosed  portion  or  above  it. 
It  is  better  in  these  cases  to  open  the  oesophagus  above  and  attempt 
to  find  the  upper  opening  of  the  stricture.  This  can  then  be  enlarged 
by  a  cutting  instrument  or  by  the  passage  of  a  probe  or  stiff  bougie. 

In  exceptional  cases,  excision  of  the  entire  segment  has  been 
successfully  carried  out  (Kendal  Franks).  The  skin  of  the  neck  has 
been  emploved  to  make  good  the  portion  which  has  been  removed 
(von  Hacker). 


OliS'l  RUCTION    I- ROM   TUMOURS 

Recently,  attempts  have  been  made  to  bring  a  d  loop  ol 

jejunum  up  under  the  Bkin,  and  by  anastomosing  it,  with  the  oesophaj 
above  the  stricture,  and  with  the  stomach  below,  to  reconstitute  a 
gullet. 

Non-Malignant  Tumours 

These  comprise  polypi,  fibromas,  myomas,  lipomas,  warts,  and 
retention  cysts  (mucous  glands).  All  of  them  are  so  rare  as  to  be  of 
little  surgical  interest. 

The  polypi  arc  perhaps  the  least  uncommon.  They  usually  occur 
in  the  upper  part  of  the  oesophagus  in  elderly  males.  They  are 
fibromas,  and  generally  contain  fat  in  their  structure.  The  tumour 
may  develop  a  long  stalk,  and  cases  have  been  published  in  which 
the  polypi  protruded  into  the  pharynx  and  could  be  seen  through  the 
mouth.  The  pedicle  is  generally  attached  to  the  anterior  wall  of 
the  oesophagus  below  the  cricoid.  They  may  give  rise  to  no  symptoms, 
but  if  large  may  cause  dysphagia,  and  if  protruded  upwards  may 
induce  attacks  of  dyspnoea  and  alteration  in  the  voice. 

They  are  treated  by  removal,  after  division  of  the  stalk,  by  means 
of  a  suitable  snare. 

Polypi  have  been  removed  through  the  mouth.  The  tumour  is 
ejected  and  held  in  position,  the  pedicle  ligatured  and  cut  through. 
If  this  be  found  impossible,  it  should  be  removed  through  an 
oesophagotomy  opening.  If  situated  in  the  lower  portion  of  the 
oesophagus  (an  uncommon  s"ite)  it  is  possible  that  the  tumour  might 
be  removed  with  the  help  of  the  oesophagoscope  (von  Hacker). 

Malignant  Tumours 
Carcinoma  of  the  (Esofhagus 

It  has  been  estimated  that  about  5  per  cent,  of  all  carcinomas 
arise  in  the  mucous  membrane  of  the  oesophagus.  The  growth  most 
commonly  begins  in  the  epithelium,  and  is  a  typical  squamous-celled 
carcinoma.  Less  frequently  the  epithelium  of  the  glands  in  the  mucous 
membrane  undergoes  carcinomatous  change  and  develops  a  tumour 
composed  of  cylindrical  cells  (Franke).  In  30  cases  of  malignant 
disease  of  the  oesophagus,  Perry  and  Shaw  found  28  squamous-celled 
epitheliomas  and  2  sarcomas.  A  colloid  growth  is  occasionally  me1 
with. 

In  its  early  stages  the  carcinoma  is  limited  to  the  mucous  membrane 
and  involves  only  a  small  portion  of  the  wall  of  the  tube;  it  tends 
to  spread  along  the  surface  of  the  mucous  membrane,  either  trans- 
versely, so  as  to  involve  the  whole  circumference  in  an  annular 
form  (Fig.  357),  or  longitudinally,  giving  rise  to  a  growth  of  I 
extent  (Fig.    358).     The  former  condition  is  more   commonly  found. 


284 


THE   (ESOPHAGUS 


As  the  growth  extends,  it  infiltrates  the  outer  coats  and  may  pene- 
trate the  muscular  wall  and  invade  the  peri-cesophageal  tissues. 


Fig.  357. — Annular  carcinoma  of 
upper  end  of  oesophagus. 

(Royal  College  of  Surgeons  Museum.) 


Fig.  358. — Diffuse   carcinoma 
of  oesophagus. 

il  College  o/  Surge  of  is  Museum.} 


A  primary  growth  in  one  part  of  the  oesophagus  has  been  found 
to  be  associated  with  other  growths  lower  down,  suggesting  the 
possibility  of  a  secondary  implantation. 


(ESOPHAGEAL   CARCINOMA 


585 


Metastatic  growths  from  oesophageal  carcinoma  have  been  recorded, 
but  are  of  rare  occurrence. 

Glandular  deposits  are  frequently  noted.  The  lower  deep  cer- 
vical glands  mi  either  aide 
Eected  when  the  prim- 
ary growl  li  is  situated  in  the 
upper  pari  of  the  oesophagus. 
Growths  in  the  thoracic  por- 
tion lead  to  involvement  of 
t  be  mediastinal  glands. 

As  the  growth  extends 
outwards  into  the  muscular 
wall  it  may  finally  penetrate 
to  those  structures  in  close 
relation  to  the  oesophagus. 
Peri  -  oesophageal  adhesions 
and  infiltration  lead  to  im- 
plication of  nerves,  viz.  the 
vagi,  recurrent  laryngeal,  and 
sympathetic.  Perforation  of 
the  large  vessels  in  the 
thorax,  or  of  those  portions 
of  the  air-passages  in  close 
relation  to  the  oesophagus, 
have  been  noted  in  many 
cases  (see  Fig.  359).  Less 
commonly  the  pleura  and 
lungs  are  involved. 

Perforation  of  the  lung- 
leads  to  gangrene  and  cavity 
formation,  with  possible  se- 
condary erosion  of  branches 
of  the  pulmonary  artery. 

In  70  cases  of  perforation 
into  the  air-passages  collected 
by  Zenker  and  von  Ziemssen 
(Kraus),  26  involved  the  right 
or  left  bronchus,  21  the  trachea. 
In  23  cases  the  lungs  were  in- 
vaded ;  the  right  lung  was  three 
times  more  commonly  affected 
than  the  left. 


The  pleural  cavity  is  sel- 
dompenetrated.  The  posterior 


Fig.  359. — Extensive  carcinoma  of 
oesophagus  opening  into  trachea. 

{London  Hospital  Pathological  Department^ 


286  THE   (ESOPHAGUS 

mediastinum  on  the  right  side  may  be  invaded,  and  a  ease  of  ex- 
tensive subcutaneous  emphysema  has  been  recorded  as  the  result  of 
this  occurrence. 

An  oesophageal  cancer  sometimes  extends  to  the  pericardium. 

A  carcinomatous  ulcer,  situated  at  the  upper  or  lower  end  of  the 
cesophagus,  may  spread  to  the  pharynx  or  stomach  respectively.  At 
the  upper  end  the  ulcer  may  extend  (a)  forwards  over  the  cricoid, 
and  involve  the  arytenoids  or  larynx,  or  (b)  backwards,  and  become 
adherent  to,  or  even  erode,  the  vertebrae. 

Growths  at  the  cardiac  end  have  been  seen  to  spread  for  some 
distance  into  the  wall  of  the  stomach.  Carcinoma  of  the  cardiac 
end  of  the  stomach  spreads  to  the  cesophagus.  Of  20  cases  of  malig- 
nant disease  of  the  cardiac  end  of  the  stomach,  in  10  it  had  invaded 
the  cesophagus  for  some  distance  (Fawcett). 

It  would  appear  that  the  growth  is  sometimes  determined  by  some 
previous  change  in  the  epithelium,  such  as  scarring  due  to  old  ulcera- 
tion from  various  causes.  The  common  location  of  the  growth  in  the 
narrow  portion  of  the  wall  suggests  that  irritation  may  be  a  factor 
in  its  development.  It  has  frequently  been  noted  that  oesophageal 
carcinoma  is  associated  with  raised  plaques  of  thickened  epithelium 
scattered  over  other  portions  of  the  mucous  membrane.  They  appear 
to  be  analogous  with  leucoplakia  of  the  tongue,  and  their  association 
with  carcinomatous  change  is  most  significant  of  the  presence  of  some 
chronic  irritation. 

Sex-  and  age-incidence.  —  Carcinoma  of  the  cesophagus  is 
essentially  a  disease  of  the  male  sex.  It  is  estimated  that  about 
80  per  cent,  of  the  cases  occur  in  males.  A  family  history  of  car- 
cinoma was  found  in  6  per  cent.  (Kolleston).  It  is  a  disease  of  later 
life,  and  but  seldom  met  with  before  the  age  of  40.  In  the  female 
sex  it  is  found  to  occur  at  a  somewhat  earlier  period  (Rolleston).  Its 
greater  frequency  in  the  male  sex  has  been  attributed  to  the  greater 
liability  to  irritation  from  tobacco,  alcohol,  etc.,  and  jDOssibly  to  the 
more  frequent  occurrence  of  syphilitic  lesions. 

Distribution.  —  Carcinoma  tends  to  arise  in  certain  well- 
defined  areas  of  the  oesophageal  wall.  It  affects  the  narrow  portions 
of  the  tube,  namely,  the  origin,  the  neighbourhood  of  the  tracheal 
bifurcation,  and  the  lower  end. 

The  relative  frequency  with  which  carcinoma  involves  any  one  of  these 
portions  has  been  a  matter  of  dispute.  Mackenzie  (1875)  maintained  that 
the  upper  portion  of  the  cesophagus  was  affected  in  40  per  cent,  of  all  cases. 
Other  authorities  (von  Hacker,  Butlin,  Rolleston)  favoured  the  lower  portion 
and  the  part  in  relation  to  the  tracheal  bifurcation.  Von  Hacker  (Kraus) 
in  100  cases  found  that  40  per  cent,  arose  at  the  tracheal  bifurcation,  and 
30  per  cent,  at  the  lower  end,  whilst  only  10  per  cent,  involved  the  upper 
portion.     Von  Bergmann  maintains  that    the  region  of    the  bifurcation  of 


OESOPHAGEAL  CARCINOMA:    SYMPTOMS       287 

the  traohea  is  the  most  oommoa  situation  of  cancer.  Butlin  points  oul 
thai  the  lower  half  of  the  cesophagas  is  much  more  oommonly  affected  than 
tho  upper.  Bolleston  (Clifford  AJlbutt)  noted  thai  in  women  the  upper 
portion  was  more  commonly  affected.  Keen  ("Textbook")  states  that  in 
68  per  cent,  tho  oaroinoma  is  situated  in  t lie  lower  portion  of  tin-  oesophagus, 
between  t ho  hilus  of  the  lung  and  the  oardia. 

Of  214  cases  quoted  by  Rawling,  only  24  occurred  in  the  cervical  region, 
whilst  163  were  in  the  thoracic  portion  of  the  oesophagus.  Sauerbrucb 
in  186  oases  found  that  -<>  were  at  the  commencement,  43  at  the  bifurcation 
of  the  trachea,  and  117  at  the  cardiac  end. 

Symptoms.  A  gradual  onset  of  dysphagia  associated  with  loss 
of  flesh  and  strength,  occurring  in  an  elderly  male  patient,  is  generally 
indicative  of  the  presence  of  a  carcinomatous  obstruction  in  the 
oesophagus. 

The  dysphagia  occasionally  comes  on  suddenly.  As  a  rule,  pain 
is  absent  until  the  disease  is  advanced,  but  even  in  the  early  stages 
complaints  may  be  made  of  a  feeling  of  tightness  in  the  throat  or  of 
vague  feelings  of  discomfort  in  the  chest  when  food  is  swallowed. 
Loss  of  body-weight  and  strength  are  comparatively  early  symptoms. 
The  dysphagia  is  at  first  slight,  but  later  is  slowly  progressive.  A 
difficulty  in  swallowing  dry,  solid  food  is  first  experienced,  then  semi- 
solid food  cannot  be  taken  into  the  stomach  without  some  delay  ; 
later  still,  only  liquids  or  very  finely  divided  substances  can  pass  down. 
At  a  still  later  stage,  fluids  tend  to  regurgitate  unless  taken  slowly  ; 
and  in  the  final  stages,  even  fluids  cannot  pass  the  site  of  the 
obstruction.  Pain,  as  previously  mentioned,  is  not  an  early  symptom  ; 
when  it  occurs  it  is  generally  coincident  with  the  taking  of  food.  It 
is  often  referred  to  the  sternum  when  the  stricture  is  in  the  lower  half 
of  the  oesophagus  ;  thence  it  radiates  to  the  back  of  the  shoulders,  or 
even  up  to  the  throat.  If  the  growth  is  in  the  upper  part  the  pain 
is  referred  to  the  neck  on  each  side.  In  growths  at  the  cardiac  end, 
pain  may  be  entirely  absent. 

In  the  later  stages,  symptoms  arise  which  depend  on  the  position 
of  the  growth  and  its  spread  to  neighbouring  structures.  An  ulcerating 
growth  at  the  upper  part  generally  leads  to  much  laryngeal  irritation, 
distressing  cough,  or  expectoration  of  frothy  mucus  associated  with 
fetor. 

Severe  bleeding  is  rare,  unless  a  large  vessel  becomes  involved, 
but  blood-stained,  foul -smelling  mucus  is  brought  up  in  late  ulcerating 
growths  situated  at  any  part  of  the  tube.  The  breath  acquires  an 
offensive  fetor. 

In  some  cases  the  voice  becomes  altered  and  develops  the  character 
suggestive  of  paralysis  of  a  vocal  cord. 

In  long-standing  cases,  symptoms  of  encroachment  on  the  air- 
passages  by  the  growth  may  develop. 


288  THE   (ESOPHAGUS 

The  diagnosis  is  made  (1)  by  a  consideration  of  the  above- 
mentioned  symptoms,  (2)  by  certain  routine  methods  of  examination 
conducted  in  a  methodical  manner  in  order  to  exclude  the  many  other 
causes  of  dysphagia. 

Careful  inspection  and  palpation  of  the  neck  should  be  undertaken 
to  eliminate  tumours  originating  either  in  the  lymphatic  glands,  the 
thyroid  gland,  or  the  vertebra?.  Increased  fixation  or  undue  bulkiness 
of  the  oesophagus  can  be  noted.  Earely,  the  presence  of  a  pharyngeal 
diverticulum  may  be  discovered  by  this  means. 

Evidence  of  alteration  of  the  pupils  should  be  noted,  or  inequality 
of  the  palpebral  fissure.  Signs  of  venous  obstruction,  or  increased 
hyperemia  of  one  side  of  the  face,  are  suggestive. 

External  examination  of  the  thorax  should  next  be  undertaken, 
and  the  condition  of  the  heart  and  lungs  carefully  noted.  The  upper 
abdomen  should  then  be  palpated  for  the  presence  of  a  possible  tumour. 

The  methods  employed  in  the  internal  examination  of  the  oesophagus 
have  been  previously  described.     They  include — 

(1)  Examination  by  sounding  ;  (2)  the  employment  of  X-rays  and 
fluorescent  screen  after  the  administration  of  bismuth  by  the  mouth  ; 
(3)  examination  with  the  laryngoscope  and  the  cesophagoscope. 

1.  Examination  with  bougies. — This  method  is  most  commonly 
employed,  and  is  of  great  practical  value.  By  its  means  the  site, 
extent,  and  permeability  of  an  oesophageal  stenosis  can  be  estimated. 
In  careful  hands  the  risks  of  this  procedure  are  slight.  The  chief 
dangers  are — (a)  perforation  of  the  wall  of  the  oesophagus,  already 
thinned  by  an  ulcerating  growth  ;  (b)  rupture  of  a  sac  in  cases  of 
aortic  aneurysm. 

The  former  danger  can  be  minimized,  in  cases  where  the  growth 
appears  to  be  of  long  duration,  by  employing  a  soft  stomach-tube  in 
place  of  the  usual  gum-elastic  or  whalebone  sound.  Careful  con- 
sideration of  the  symptoms  and  physical  signs  should  render  the  latter 
risk  an  unlikely  one. 

Gum-elastic  sounds,  either  oval  or  round,  should  be  used,  or 
Symonds's  whalebone  sound  with  olive-shaped  end.  The  sound  is 
passed  as  described  at  p.  257. 

If  an  obstruction  be  felt,  no  attempt  should  be  made  to  push  the 
instrument  forcibly  past  the  constricted  part.  A  smaller-sized  bougie 
should  be  used,  and  gradually  smaller  ones  inserted  until  one  is  felt 
to  pass  the  site  of  the  obstruction. 

By  the  employment  of  Symonds's  sounds  the  length  of  the  con- 
stricted portion  can  be  measured. 

2.  Examination  with  X-rays. — Radiography  after  the  adminis- 
tration of  bismuth  is  now  extensively  employed  in  this  condition. 
Its  chief  value  is  to  exclude  the  presence  of  a  pouch  or  foreign  body. 


(ESOPHAGEAL    CARCINOMA:    TREATMENT     28g 

The  presence  of  the  stricture  can  be  shown  by  the  Btoppage  of  the 
bismuth,  given  either  as  a  suppository  or  as  an  emulsion.  If  in  the 
latter  form,  it  will  be  seen  to  collect  and  form  an  oblong  opaque 
shadow.  Bomewhal  cone-shaped,  with  the  base  uppermost.  The  apex 
of  the  cone  points  into  the  mouth  of  the  stricture,  through  which  tin- 
solution  may  be  seen  to  drop  down  slowly  into  the  stomach.  In 
early  growths,  when  slight  stenosis  exists,  the  method  is  of  little 
value.  I  have  observed  a  case  in  which  bismuth  solution  passed 
into  the  stomach,  but  sounds  could  not  be  made  to  pass  the  site 
of  the  growth. 

In  doubtful  cases  of  aneurysm  the  method  is  of  great  value,  as 
the  use  of  sounds  is  contra-indicated.  The  presence  of  the  aneurysm 
may  be  demonstrated  by  a  pulsating  shadow,  and  a  stricture  by  the 
dense  opacity  produced  by  the  retained  bismuth. 

3.  Direct  inspection  with  the  cesophagoscope — This  method 
gives  the  most  exact  information  as  to  the  character  and  extent  of 
an  oesophageal  growth.  By  its  means  portions  of  the  tumour  can 
be  removed  for  microscopical  examination,  and  local  applications 
can  be  made  or  radium  applied.  The  employment  of  this  instrument, 
however,  is  not  to  be  advised  as  a  routine  method  of  examination  in 
general  practice.  The  introduction  of  an  cesophagoscope,  even  under 
anaesthesia,  is  a  proceeding  which  entails  certain  risks  and  requires 
technical  experience.  The  diagnosis  of  an  oesophageal  carcinoma  can 
generally  be  confidently  made  without  its  use.  It  is  invaluable  in 
cases  in  which  the  diagnosis  of  a  malignant  growth  is  doubtful,  or 
in  which  treatment  by  radium,  or  some  other  local  application,  is 
thought  advisable.  As  seen  through  the  cesophagoscope,  a  carcinoma 
of  the  mucous  membrane  of  the  wall  can  be  easily  recognized.  In  the 
very  early  stages  only  a  slight  swelling  may  be  seen,  but  in  the  average 
case  the  raised  ragged  edge  of  the  growth  and  the  ulcerating  surface 
are  quite  distinctive.  The  fixation  of  the  oesophageal  wall  at  the 
site  of  the  growth  is  a  noticeable  feature,  and  the  natural  rhythmic 
respiratory  movements,  which  are  always  present  in  the  healthy 
oesophagus,  are  absent. 

Examination  with  the  laryngoscope  will  only  reveal  a  growth 
situated  at  the  commencement  of  the  oesophagus.  This  instrument, 
however,  should  be  employed  in  every  case  in  order  to  investigate 
the  condition  of  the  vocal  cords. 

Treatment. — Operations  for  the  removal  of  carcinoma  of  the 
oesophagus  have  up  to  the  present  time  met  with  but  little  success. 
Excision  of  growths  in  the  cervical  portion  have  only  been  tem- 
porarily successful.  Records  of  15  cases  treated  by  cervical 
oesophagectomy  have  been  collected  by  Quervain,  and  these  include 
the  well-known  cases  operated  on  by  Czerny,  Mikulicz,  and  Garre. 


290  THE   (ESOPHAGUS 

The  results  are  gloomy  :   5  patients  died  as  the  result  of  the  operation, 
and  no  case  survived  for  longer  than  thirteen  months. 

In  Czerny's  case  the  upper  end  of  the  lower  segment  of  the 
oesophagus  was  fixed  to  the  margins  of  the  skin  wound,  and  the 
patient  was  fed  by  means  of  a  tube. 

The  field  of  this  operation  is  a  limited  one  ;  it  is  only  suitable 
for  small  growths  situated  in  the  upper  part  of  the  oesophagus.  The 
risks  of  infection  are  great,  and  it  is  generally  found  impossible  to 
restore  the  continuity  of  the  oesophageal  wall  after  thorough  excision 
of  the  growth. 

In  the  majority  of  cases,  carcinoma  invades  the  thoracic  portion 
of  the  oesophagus,  and  the  dangers  and  difficulty  of  attempting  its 
removal  by  operation  can  be  easily  understood. 

The  operation  of  thoracic  (Esophagectomy  is  one  of  great 
difficulty  and  of  peculiar  danger  owing  to  the  effect  of  the  atmospheric 
pressure  on  the  lungs.  In  order  to  overcome  the  evil  results  of  the 
atmospheric  pressure,  various  forms  of  apparatus  have  been  devised. 
(See  under  Respiratory  System,  Vol.  III.,  p.  266.)  Although  by  these 
means  one  risk  of  this  operation  has  been  minimized,  yet  the  anatomi- 
cal difficulties  of  extirpating  a  growth  in  this  portion  of  the  oesophagus 
are  still  present.  The  wall  of  the  oesophagus,  unlike  that  of  the 
intestine,  cannot  be  freely  excised  with  any  prospect  of  a  successful 
union  of  the  divided  ends.  An  end-to-end  anastomosis  by  suture  is 
rarely  feasible.  If  sutures  are  used,  they  have  a  tendency  to  cut  out 
owing  to  tension  and  the  constant  movement  in  the  thorax.  The 
absence  of  omentum  and,  more  important  still,  of  a  serous  coat 
on  the  oesophageal  wall,  are  conditions  prejudicial  to  satisfactory 
union. 

The  total  number  of  reported  operations  on  the  oesophagus  by 
thoracotomy  is  39  (Meyer).  In  21  cases,  resection  of  a  growth  was 
carried  out ;  in  9  cases,  exploratory  thoracotomy  was  satisfactorily 
performed.  There  were  no  cases  of  recovery  after  resection.  This 
operation  will  probably  only  be  practicable  in  the  lower  portion  of 
the  oesophagus.  A  cone-shaped  portion  of  the  stomach  wall  is  drawn 
up  into  the  thorax  and  anastomosed  to  the  oesophagus  on  the  proximal 
side  of  the  growth.  This  operation,  known  as  cesophago-gastrostor/u/, 
has  been  performed  by  Sauerbruch  and,  in  dogs,  by  Willy  Meyer, 
who  thinks  that  the  operation  may  have  a  future  if  carried  out  in 
two  stages  and  conducted  in  the  "  positive  differential  pressure 
chamber."  In  the  first  stage,  thoracotomy  is  performed,  and  the 
cone-shaped  portion  of  the  stomach  brought  up  and  transferred  into 
the  thorax  through  an  opening  in  the  diaphragm.  In  the  second  stage, 
two  or  three  weeks  later,  the  growth  is  resected  and  the  oesophago- 
gastrostomy  completed. 


(ESOPHAGEAL  CARCINOMA:  TREATMENT 

Meyer  says  that  the  stomach  can  only  be  pulled  up  Eoi  '■>  \  in, 
into  the  thorax. 

For  tumours  situated  in  the  middle  and  upper  portions,  Meyei 
recommends  excision  of  the  growth,  when  possible,  with  closure  by 
inversion  of  the  divided  ends  and  gastrostomy.  The  upper  end  may 
l>e  sin  uied  t..  t  lie  skin,  and  an  at  tempt  made  later  to  unite  it,  by  various 
means  with  the  gastric  opening.  Tin's  has  been  done  by  the  use  of 
an  instrument  or  the  employmenl  of  a  portion  of  the  small  intestine 
(Roux,  Kocher,  Turner,  Kiimmell). 

Sauerbruch  considers  that  growths  at  the  lower  end  of  the 
o'sopliagus  are  most  favourable  for  removal.  They  form  late  metas- 
tases, and  do  not  spread  locally  with  rapidity.  He  recommends 
that,  if  the  tumours  be  small,  the  end  of  the  oesophagus  should  be 
invaginated  into  the  stomach  and  resected  later.  He  prefers  the 
u-e  of  the  Murphy  buttons  to  sutures. 

Janeway  and  Green  advocate  removal  of  the  major  portion  of 
the  stomach  in  cases  of  growth  involving  both  the  lower  portion  of  the 
oesophagus  and  the  cardiac  end  of  the  stomach.  Through  an  abdo- 
minal incision  the  stomach  is  loosened  from  its  mesenteric  attach- 
ments. The  thorax  is  opened,  and  the  stomach  brought  up  through 
an  opening  in  the  diaphragm.  The  pylorus  is  then  divided.  The 
oesophagus  is  cut  across  above  the  growth,  and  the  ends  of  the 
oesophagus  and  pylorus  are  united  by  suture.  The  pylorus  is  then 
secured  to  the  opening  in  the  diaphragm.  This  operation  has  been 
carried  out  with  success  in  dogs. 

Palliative  measures. — Short  of  removal  of  the  growth,  the 
indications  are  to  prevent  starvation  of  the  patient  (which  will 
inevitably  ensue)  and  to  add  to  his  comfort. 

The  increasing  dysphagia  may  be  relieved  by — 

1.  The  passage  of  sounds  or  bougies  from  time  to  time. 

2.  The  introduction  of  feeding-tubes. 

3.  Application  of  radium. 

4.  Cervical  cesophagostomy. 

5.  Gastrostomy. 

1.  The  periodical  passage  of  sounds  in  order  to  dilate  a 
malignant  stricture  has  some  value,  but  it  is  not  advisable  as  a 
routine  practice.  The  passage  of  the  sound  may  cause  bleeding, 
and  no  doubt  in  some  cases  hastens  the  spread  of  an  ulcerating 
growth.  The  relief  obtained  is  at  best  only  temporary,  and  swelling 
of  the  mucous  membrane,  induced  by  the  sounding,  may  increase 
the  dysphagia. 

2.  Permanent  intubation  of  the  oesophagus  by  means  of 
Symonds's  funnel-shaped  feeding-tubes  passed  through  the  stricture 
has  been  widely  employed.     The  tubes  are  introduced  by  means  of 


292  THE   OESOPHAGUS 

an  instrument  inserted  into  the  funnel-shaped  upper  extremity.  They 
may  be  left  in  situ  for  several  months.  A  piece  of  silk  fastened  to 
the  upper  end  is  brought  out  of  the  mouth,  and  secured  to  the  aurich' 
or  cheek.  The  patient  is  able  to  swallow  and  enjoy  nourishment. 
This  procedure  is  not  suitable  for  strictures  in  the  upper  part  of  the 
oesophagus,  as  the  tube  is  apt  to  irritate  the  larynx.  The  disadvantages 
are  that  the  tubes  get  very  foul,  may  require  to  be  frequently  changed, 
and  sometimes  tend  to  stimulate  the  spread  of  an  ulcerating  growth. 
Jacobson  recommends  their  employment  so  long  as  the  patient  can 
swallow  sufficient  food  by  this  means. 

In  discussing  this  method  of  treatment,  Symonds  summarizes 
as  follows  : — 

(a)  In  cricoid  obstruction  the  long  rubber  tube  gives  good  results. 

(b)  In  disease  of  the  central  portion  of  the  oesophagus  the  short 
tube  is  advised,  though  if  pulmonary  symptoms  arise  the  long  tube 
is  substituted  for  it. 

(c)  In  disease  of  the  cardiac  orifice,  gastrostomy  is  preferable  to 
intubation. 

Success  has  recently  followed  the  use  of  a  permanent  feeding-tube 
devised  by  William  Hill  and  consisting  of  a  malleable  silver  stilette 
of  small  diameter  surrounded  by  a  rubber  tube.  This  is  passed  through 
the  stricture  with  the  aid  of  the  cesophagoscope.  It  can  be  used  even 
when  the  obstruction  is  at  the  lowest  portion  of  the  oesophagus.  The 
upper  end  is  fixed  to  the  teeth.  It  is  surprising  how  soon  food 
can  be  swallowed  beside  this  tube,  and  its  presence  is  generally  well 
tolerated. 

3.  Radium  has  been  employed  recently  in  carcinoma  of  the  oeso- 
phagus, with  some  hopeful  results.  A  small  tube  containing  radium 
is  passed  down  by  means  of  the  cesophagoscope,  and  left  for  some  hours 
within  the  stricture.  In  some  cases  ulceration  and  fungation  of  the 
growth  have  disappeared,  and  the  lumen  has  markedly  increased  so 
that  feeding-tubes  can  be  inserted  (Hill,  Finzi). 

4.  The  operation  of  cervical  cesophagostomy,  whereby  an 
opening  is  made  in  the  oesophagus  in  the  neck,  has  little  to  recommend 
it.  It  can  only  be  employed  when  the  growth  is  at  the  upper  end 
of  the  oesophagus.  The  reasons  against  it  are  thus  epitomized  by 
Fagge  :— 

(1)  The  greater  difficulty  and  danger  of  the  operation. 

(2)  The  difficulty  of  making  the  opening  sufficiently  below  the 
growth  to  prevent  later  involvements. 

(3)  Discomfort  from  the  flow  of  saliva  over  the  wound,  and  risk 
of  local  infection  of  the  cellular  tissues  from  this  source. 

5.  Treatment  by  gastrostomy  is  indicated  when  intubation  has 
proved  unsatisfactory. 


OESOPHAGEAL   CARCINOMA:    TREATMENT      293 


Comparatively  receni  technical  improvements  have  greatly  incn 

the    value    of    this    operation.     The    disheartening    results    previously 
experienced  through  leakage  of  stomach  contents  can  now  be  avoided. 


AORTA 

SURROUNDED  BY 

GROWTH 


OESOPHAGUS 


GROWTH 


Fig    360. — Obstruction  to  the  oesophagus  caused   by  a  mediastinal 

growth. 

{London  Hospital  Pathological  Department^ 


294  THE   (ESOPHAGUS 

By  any  of  the  modern  methods  in  use  a  perfectly  dry  wound  can 
be  guaranteed.  The  results  would  be  better  still  if  only  the  operation 
were  performed  before  the  patient  is  in  a  state  of  starvation,  as  is 
onlv  too  often  the  case. 

Leakage  of  stomach  contents  after  a  gastrostomy  operation  is 
prevented  by  the  formation  of  a  valvular  opening,  which  is  constructed 
by  one  of  the  following  methods  : — 

(1)  Inversion  of  a  cone-shaped  portion  of  the  anterior  wall  of  the 
stomach  round  a  rubber  feeding-tube,  inserted  through  a  small  opening, 
and  fixed  by  absorbable  sutures.  The  cone-shaped  portion  is  inverted, 
and  secured  either  by  rows  of  purse-string  sutures,  after  the  method 
of  Senn  or  Abbe,  or  by  means  of  layers  of  transverse  sutures  inserted 
on  the  Lembert  principle  (Kader's  operation). 

(2)  The  tube  is  passed  through  a  small  opening  in  the  anterior  wall 
of  the  stomach,  and  some  inches  of  the  tube  are  secured  in  a  groove 
formed  by  two  ridges  of  the  wall  sutured  over  it  (Witzel's  method). 

In  each  of  the  above  methods  the  stomach  wall  is  secured  to  the 
abdominal  wall  by  sutures. 

(3)  The  principle  adopted  by  Frank  and  modified  by  other  surgeons 
(viz.  Kocher,  Albert  and  Cheyne)  depends  on  drawing  up  a  cone-shaped 
portion  of  the  stomach  wall,  which  is  fixed  at  its  base  to  the  opening 
in  the  abdominal  parietes.  The  cone  is  then  passed  beneath  the 
skin,  or  through  the  rectus  muscle,  and  its  summit  fixed  to  the  edges 
of  a  second  smaller  opening  made  either  above  or  to  one  side  of  the 
original  incision.  By  this  means  a  subcutaneous  oesophagus  composed 
of  stomach  wall  is  formed.  The  opening  into  the  stomach  is  finally 
completed  a  few  days  later. 

All  the  above  methods  of  operation  are  valuable.  In  my  experience 
the  operation  devised  by  Senn  has  given  extremely  good  results. 
Leakage  can  be  certainly  avoided,  the  operation  is  very  simple,  and 
the  patient  can  be  fed  immediately. 

Sarcoma  of  the  (Esophagus 

Primary  growths  of  this  nature  are  very  rare,  but  have  been 
reported.  They  are  either  spindle-  or  round-celled,  and  are  some- 
times pedunculated  (Albrecht)  They  are  more  commonly  situated 
at  the  entrance  of  the  oesophagus,  or  near  the  bifurcation  of  the 
trachea  (Bergmann).  The  primary  growth  may  lead  to  secondary 
bony  metastases  (Rolleston).  One  primary  lympho-sarcoma  has  been 
reported. 

Secondary  sarcomatous  growth  in  the  oesophagus  is  generally  an 
extension  from  neighbouring  bones  or  soft  structures  in  the  neck  or 
thorax.  The  employment  of  the  cesophagoscope  is  necessary  for  the 
correct  diagnosis  of  this  condition. 


KIHLIOGRAPHY  295 

EXTRINSIC   CAUSES  OF  OBSTRUCTION 

In  any  pari  of  its  course  the  oesophagus  may  be  pressed  upon  or 
invaded  by  a  tumour  <>r  swelling  arising  in  neighbouring  tissues.  Such 
obstruction  may  be  duo  to  aneurysm,  enlarged  glands,  new  growths, 
or  abscess,  and  is  more  apt  to  occur  within  the  thorax  than  in  the  neck. 
An  example  of  obstruction  caused  by  a  mediastinal  new  growth  is 
Been  in  Fig.  3(10.  For  a  description  of  extrinsic  forms  of  obstruction 
the  reader  must  be  referred  to  other  parts  of  this  System  or  to  text- 
books of  Medicine. 

BIBLIOGRAPHY 

Malformation's 

Ballantyne's  Antenatal  Pathology,  ii.  462.     1904. 

Keith,  Textbook  of  Embryology. 

Keith  and  Spicer,  Journ.  Anal,  and  Phys.,  xli.  53. 

Lotheissen,  in  Bergmann's  Surgery. 

Shattock,  Trans.  Path.  Soc,  1890,  xli.  87. 

Spicer,   Lancet,    1907,   i.    157. 

Whipham  and  Fagge,  Lancet,  1905,  i.  22. 

Diverticula 

Butlin,  Brit.  Med.  Journ.,  July  11,  1903. 

Halsted,  Ann.  of  Surg.,  1904. 

Jacobson  and  Rowlands,  Operations  of  Surgery,  5th  edit. 

Keith,  Lectures  at  the  R.C.S.,  Brit.  Med.  Journ.,  1910,  i.  370. 

Lanner,  Beitr.  z.  Anat.  des  (Esophagus. 

Mayo,  Ann.  of  Surg.,  July,  1910. 

Pathologie   und  Therapie,   Leipzig,   1877,  vii.,  Abteilung  i. 

Richardson,  Maurice,  Ann.  of  Surg.,  1900. 

Robertson,  Results  of  Operations  for  Pouches. 

Stetten,  Ann.  of  Surg.,  1910.     (With  complete  bibliography.) 

Wien.  med.  Jahrb.,  1883,  S.  364. 

Zenken  and  von  Ziemssen,  Krankheiten  des  (Esophagus. 

Zesas,  Deuts.  Zeits.  f.  Clin.,  1906,  lxxxii.     (42  cases,  8  deaths;    fistula;  formed 

in  all  but  6  cases.) 
von  Ziemssen,  Handbuch  der  Speiserohre. 

Rupture 

Bowles  and  Turner,  Med.  Clin.  Trans.,  1899,  lxxxiii.  241-255. 
Rolleston,  Trans.  Path.  Soc,  1893,  xlv.  58. 
West  and  Andrews,  Trans.  Path.  Soc,  1896,  xlviii.  73-77. 
Williams,  Trans.  Path.  Soc,  1846,  i.  151. 

Foreign  Bodies 

Allen,  N.  Y.  Med.  Journ.,  1895,  hrii.  203-10. 

Black,  Amer.   Med.,  Philadelphia,  1905,  ix.   155. 

Bryant,  Operative  Surg.,  ii.  1288. 

Burghard,  Syst.  of  Op.  Surg.,  vol.  ii.  ;    Fagge,  p.  273.     Rei.  to  Killian,  Zeits.  f. 

Ohrenheilk.,  1908,  i.  120. 
Church,  "  CEsophagotomy,"  St.  Bart's  Hosp.  Repts.,  xix.  67. 
Fullerton,  "  CEsophagotomy,"  Brit.  Med.  Journ.,  1904. 
von   Hacker,  Bergmann's  Syst.  of  Surg.,  vol.  iv. ;  Deuts.  med.  Woch.,  1905,  xxxi. 

1535. 
Jacobson,  "  CEsophagotomy,"  Operations  of  Surgery,  i.  724. 


296  THE   (ESOPHAGUS 

King,  N.  Y.  Med.  Record,  1900,  lviii.  (543-5.  _ 

Lawson,  "  (Esophagotomy  for  Tooth-Plate,"  Clin.  Soc.  Tram.,  xvm.  292. 

Lediard,  Clin.  Soc.  Trans.,  xviii.  297. 

Littlewood,  ';  Four  Cases  of  Tooth-Plates,"  Lancet,  Aug.   12,   190o. 

Madntyre,  Journ.  of  Laryng.,  London,   1902^  xvii.  467-74. 

May,  Bennett,  Jackson's  Operative  Surg.,  i.  724. 

Richardson,  "  Accessibihty  in  Neck,"  Lancet,  1887,  ii.  707. 

Richardson,  Lancet,  1907,  vol.  ii. 

Rigby,  Ann.  of  Surg.,  1907. 

Scott,  Cleveland  Med.  Journ.,  1902,  i.  147-53. 

Tillman's  Textbook,  vol.  ii. 

Turner,  Lancet,  May,  1910. 

Obstruction 

Goldman,  Lancet,  1906,  i.  21. 

Keith,  Lancet,  1903,  i.  639. 

Kraus,  in  NothnageFs  Pathologic  und  Therapie. 

Lockwood,  Brit.  Med.  Journ,,  1903,  i.  1367. 

Mikulicz,  in  Keen's  Surgery. 

Sippey,  Ann.  of  Surg.,  1906,  xliii.  859,  945. 

Strauss,  Bed.  klin.   Woch.,  1904,  No.  49. 

String-Method  Gastrotomy 

Abbe,  Ann.  of  Surg.,  1897,  xxv.  359. 
Campbell,  Trans.  Assoc.  Amer.  Surg.,  1883,  i.  517.; 
Coombes,  Internat.  Clin.,  1904,  iv.  172-80. 
Dunham,  Ann.  of  Surg.,  1901,  xxxiv.  822. 
Franks,  Ann.  of  Surg.,  1890,  xii.  321-9. 
Johnson,  G.  R.,  N.  Y.  Med.  Times,  1900,  xxviii.  166. 
Lilienthal,  N.Y.  Med.  Journ.,  1894,  lix.  496. 
Mansell-Moullin  C,  Clin.  Journ.,  1894,  iv.  288-91. 

Treatment  of  Stricture 

Dunham,  X.  Y.  State  Journ.  of  Med.,  1903,  iii.  93-5. 
Johns  Hopkins  Hosp.  Bull.,  1905,  xvi.  147. 
Mayo,  Internat.  Clin.,  1900,  iv.  43,  54. 

Operative  Treatment 

Abbe,  Ann.  of  Surg..  1894,  xix.  88. 

Franks,  Brit.  Med.  Journ.,  1894,  ii.  973  ;   Ann.  of  Surg.,  1894,  xix.  385,  398. 

von  Hacker,  Bergmann's  Syst.  of  Surg.,  vol.  iv. 

Thomas,  Liverpool  Med.  Clin.  Journ.,  1902,  xxii.  50-3. 

Tumours  j 

Fagge,  Burghard's  Syst.  of  Op.  Surg.,  ii.  279. 

Fawcett,  Trans.  Path,  Soc,  1905,  lvi.  259. 

Frank,  Virchouis  Arch.,  1903,  clxxiv.  563. 

Hill,  Med.  Soc.  Trans.,  Feb.  13,  1911. 

Janeway  and  Green,  Ann.  of  Surg.,  July,  1910. 

Meyer,  Ann.  of  Surg.,  July,  1909. 

Perry  and  Shaw,  Guy's  Hosp.  Repts.,  1891,  xxxiii.   137. 

Quervain,  Arch.  f.  klin.  Chir.,  1899,  S.  858. 

Rawling,  Clin,  Journ.,  March  2,  1910. 

Sauerbruch,  Beitr.  klin.  Chir.,  1905,  xlvi.  405  :   Journ.  Amer.  Med.  Assoc,  ii.  803: 

Symonds,  Lancet,  1902,  ii.  353. 


THE     STOMACH    AND     DUODENUM 

By  JAMES  SHERREN,   F.R.G.S.Eng. 

Anatomy  and  physiology. — Although  the  stomach  and  duo- 
denum are  anatomically  separate,  it  is  advisable,  for  surgical  reasons, 
to  consider  them  together.  From  an  embryological  standpoint  they 
are  closely  related,  and  they  are  liable  to  similar  diseases. 

The  stomach  and  the  duodenum,  as  far  as  the  entrance  of  the 
common  bile-duct,  are  developed  from  the  foregut  and  receive  their 
blood  supply  from  the  cceliac  axis,  while  the  duodenum  below  this 
point  is  developed  from  the  midgut  and,  like  it,  is  supplied  by  the 
superior  mesenteric  artery. 

Our  conception  of  the  size  and  shape  of  the  stomach  has  altered 
during  the  last  few  years  owing  to  the  frequency  of  direct  operative 
examinations,  to  the  introduction  of  X-rays,  and  to  improved  methods 
of  anatomical  investigation.  Formerly  regarded  as  a  bag  or  sac  into 
which  the  food  dropped,  it  is  now  known  to  resemble  more  closely 
the  intestine,  and  to  be  normally  in  a  state  of  contraction. 

From  the  anatomical,  embryological,  physiological,  and  patho- 
logical standpoints  the  stomach  can  be  divided  into  two  portions, 
pyloric  and  cardiac,  which  are  in  health  functionally  separated  by 
a  band  of  transverse  muscle,  the  mid-gastric  sphincter  (Figs.  361,  362). 
The  cardiac  portion  lies  to  the  left  of  the  right  margin  of  the  cardiac 
orifice,  its  boundary  being  marked  by  a  notch  on  the  lesser  curva- 
ture. At  this  point  the  stomach  turns  almost  at  a  right  angle  to  run 
horizontally  to  the  right,  as  the  pyloric  portion. 

X-ray  examination  of  the  normal  stomach  after  the  ingestion  of 
a  bismuth  meal  reveals  the  same  condition.  Systematic  work  in  this 
method  of  examination  was  first  done  in  this  country  by  Hertz,  on 
whose  early  observations  the  following  account  is  based.  When  food 
is  swallowed  it  is  received  into  the  cardiac  reservoir,  from  which  it 
is  passed  on  into  the  pyloric  portion.  Fresh  food  swallowed  passes 
to  the  centre  of  the  mass  already  there,  the  action  of  the  ptyalin  in 
this  way  being  allowed  to  continue  unchecked  by  the  gastric  juice. 
Very  little  active  movement  takes  place  in  the  cardiac  part  of  the 

297 


298 


THE   STOMACH   AND   DUODENUM 


stomach.  The  pressure  here  has  been  shown  by  Sick  to  be  only  6  to 
8  cm.  of  water,  with  slight  and  irregular  variations.  The  musculature 
of  the  pyloric  portion  of  the  stomach  is  thick  and  is  the  seat  of 
peristaltic  waves  which  occur  at  intervals  of  about  fifteen  to  twenty 
seconds,  beginning  about  thirty  minutes  after  a  meal.  In  the  early 
stages  of  digestion  the  pylorus  is  closed  and  a  central  reflux  of  food 
occurs,  the  mass  being  pushed  backwards  and  forwards  and  thoroughly 
triturated  and  mixed  with  the  gastric  juice.  As  digestion  proceeds, 
the  pressure  in  this  part  of  the  stomach  varies  from  20  to  60  cm.  of 


+*+ 


Fig.  361. — Mid-gastric  sphincter,  as  depicted  by  Sir  Everard  Home. 

(After  Keith.) 

water.  Recent  work  by  Barclay  and  Hertz's  later  observations  have 
thrown  some  doubt  on  the  separation  into  two  compartments  as  seen 
on  X-ray  examination. 

Since  Beaumont's  time  it  has  been  considered  that  the  acidity  of 
the  gastric  contents  causes  relaxation  of  the  pylorus.  But  it  is  more 
probable  that  the  pylorus  relaxes  with  each  peristaltic  wave  which 
sweeps  over  the  pyloric  portion  of  the  stomach,  unless  inhibited  by 
reflexes  set  up  by  the  presence  of  free  acid  in  the  first  portion  of  the 
duodenum  (Pavlov).  The  presence  in  the  stomach  of  solid  particles, v 
or  of  fluids  warmer  or  colder  than  the  body  temperature,  also  causes 
closure  of  the  pylorus. 

The  time  at  which  the  food  leaves  the  stomach  varies  with  its 
nature  ;  carbohydrates  pass  out  first,  then  fats  and  proteins.  The 
cardiac  portion  of  the  stomach  is  empty  before  the  pyloric  ;  about 
six  hours  after  a  full  meal,  or  three  and  a  half  to  four  after  a  light 
meal,  the  whole  stomach  should  be  empty. 


\\  \ TOMY   OI-    TUK    DL'ODKM'M 


capacity  of  the  stomach  varies  according  to  the  amount  and 
ki:i<l  "t   food   habitnally  taken.     Eta  avei  acity,  accoidii 

Sidney  Martin,  is  36  to  1"  fluid  oz. 

The  function  of  the  stomach  is  to  prepare  food  for  absorption. 
and  so  prevent   injury  to  the  intestine.     It  renders  meals   possible, 

certain  extent  it  sterilizes  the  food,  eori> 
it  to  the  body  temperature,  and  reduces  it  to  a 
rluid  mixed  with  gastric  juice. 

The  duodenum  is  that  portion  of  the  small 
intestine  between  the  pylorus  and  the  duodeno- 
jejunal junction.  For  the  purposes  of  descrip- 
tive  anatomy  it  has  been  divided  into  three  or 
four  parts.  The  first  or  superior  portion  ex- 
tends  to  the  neck  of  the  gall-bladder,  the  second 
01  descending  ends  opposite  the  third  or  fourth 
lumbar  vertebra,  and  turns  sharply  to  the  left  as 
the  third  portion,  which  runs  across  the  spine 
and  then  ascends  to  the  left  side  of  the  first  or 

iid  lumbar  vertebra.  The  left  ascending 
portion  is  sometimes  called  the  fourth  part. 
The  more  important  division  surgically  is  into 
the  part  above  (supra -ampullary)  and  that  be- 
low (infra-ampullary)  the  entrance  of  the  com- 
mon bile-duct.  The  supra-ampullary  portion  is 
affected  by  the  diseases  that  attack  the  stomach, 
whilst  diseases  of  the  infra -ampullar}*  are  rare 
and  resemble  those  of  the  remainder  of  the 
small  intestine. 

At  the  level  of  the  junction  of  the  first  and  second  lumbar  vertebra?, 
the  gut  turns  directly  forward  at  the  duodenojejunal  flexure  to  become 
the  jejunum.  The  anatomy  of  this  region  is  of  great  importance  in 
connexion  with  the  operation  of  gastrojejunostomy  (p.  406).  The 
duodenojejunal  junction  is  held  in  position  by  a  band  of  fibres  con- 
taining unstriped  muscle  attached  to  the  left  eras  of  the  diaphragm  : 
this  is  enclosed  in  a  peritoneal  fold  which  is  usually  small,  but  occa- 
sionally, as  pointed  out  by  Mayo,  may  extend  several  inches  along 
the  jejunum.  Murphy  has  shown  that  in  the  process  of  development 
a  loop  of  jejunum  may  be  left  posterior  to  the  peritoneum.  This 
may  extend  as  low  as  the  brim  of  the  pelvis,  and  then,  passing  back- 
wards and  upwards,  may  enter  the  peritoneal  cavity  through  its 
posterior  wall,  just  below  the  level  at  which  the  duodenum  • 
the  aorta.  The  whole  of  the  small  intestine  has  been  found  in  a 
secondary  sac  bounded  by  omentum  and  mesocolon  (Malcolm). 

When  the  jejunum  is  turned  over  to  the  right,  folds  of  peritoneum 


Fig.  362.— Stomach 
of  a  full-term  foetus, 
showing  subdivision 
into  cardiac  and 
pyloric  portions. 
(After  Cunningham.) 

This  differentiation,  ac- 
cording to  Keith,  U  seen 
as  early  as  the  third  month, 
when  the  fundus  buds  out 
from  the  dorsal  border  of 
the  stomach. 


3oo  THE   STOMACH   AND   DUODENUM 

are  seen  running  from  the  duodenum  and  jejunum  to  the  parietal 
peritoneum.  Of  these,  the  inferior  and  superior,  bounding  small 
recesses  with  their  openings  directed  upwards  and  downwards  respec- 
tively, are  most  often  seen.  Hernias  may  occur  in  this  situation, 
and  may  not  only  complicate  the  operation  of  gastrojejunostomy, 
but  render  it  entirely  impracticable,  as  in  a  case  of  chronic  duodenal 
ulcer  recently  under  my  care.  A.  E.  Barker  has  placed  on  record  a 
similar  case. 

Blood-supply  of  stomach  and  duodenum. — The  stomach 
and  supra-ampullary  part  of  the  duodenum  are  supplied  with  blood 
from  the  branches  of  the  cceliac  axis. 

The  remainder  of  the  duodenum  is  supplied  from  the  superior 
mesenteric  artery  by  means  of  its  inferior  pancreatico-duodenal  branch. 
The  superior  mesenteric  vessels  have  an  important  relation  to  the 
third  portion  of  the  duodenum,  in  that  they  cross  its  middle  and  by 
the  pressure  produced  in  certain  conditions  have  been  said  to  cause 
acute  dilatation  of  the  stomach  (p.  324). 

The  veins  of  the  stomach  and  duodenum  pass  to  the  portal  system. 

Lymphatics. — Knowledge  of  the  lymphatic  system  of  the  stomach 
is  essential  to  the  correct  surgery  of  malignant  disease.  The  present 
operation  of  partial  gastrectomy  is  based  upon  the  researches  of  Cuneo, 
published  in  1900.  His  results  have  been  confirmed  and  extended  by 
Dobson  and  Jamieson,  on  whose  work  the  following  account  is  based. 

The  lymphatics  arise  around  the  glands  in  the  mucous  membrane, 
and  form  submucous,  muscular,  and  subserous  plexuses  continuous 
throughout  the  whole  of  the  stomach  and  communicating  with  those 
of  the  duodenum  and  oesophagus.  From  the  subserous  plexuses  the 
vessels  pass  out  to  enter  the  lymphatic  glands  into  which  they  drain. 
Although  no  barrier  could  be  demonstrated  by  injection  experiments 
between  the  areas  drained  by  the  several  sets  of  glands,  yet  one 
lymphatic  territory  becomes  fully  injected  before  the  fluid  spreads 
over  into  a  neighbouring  one. 

The  groups  of  lymphatic  glands  are  placed  along  the  course  of 
the  principal  blood-vessels,  and,  as  elsewhere,  they  drain  the  corre- 
sponding areas. 

The  main  groups  of  glands  are  the  following  (Fig.  363)  : — 

1.  The  coronary  set  lie  along  the  descending  branch  of  the  coronary 
artery  and  are  divided  into  two  groups,  upper  and  lower.  The  lower 
glands  lie  close  to  the  lesser  curvature  and  rarely  extend  farther  to 
the  right  than  the  mid-point  between  oesophagus  and  pylorus  ;  they 
increase  in  size  and  number  as  they  approach  the  cardia.  The  upper 
group  lie  in  the  falx  coronata  with  the  stem  of  the  artery.  The 
paracardial  are  outlying  members  of  this  group,  and  lie  around  the 
cardia,  sometimes  extending  to  the  left  of  the  cardiac  orifice  ;  occasion- 


LYMPHATIC    (il.AM)S 


301 


ally  there  are  one  or  two  glands  on  the  bare  area  of  the  stomach.  <  In 
tracing  the  upper  coronary  glands  backwards  they  become  continuous 
with  the  glands  around  the  cceliac  axis. 

2.  The  eceliac  glands,  situated  at  the  upper  border  of  the  pam  1 
have  been  divided  into  three  groups,  the  middle  (around  the  cceliac 
axis),  left  (on  the  splenic),  and  right  (on  the  stem  of  the  hepatic  artery) 
suprapancreatic.     To  the  left  suprapancreatic  group  (splenic)  belong 
the  glands  occasionally  present  in  the  gastro-splenic  omentum.     The 


Fig.  363. — Lympha 


stomach 


a,  Lower  coronary  glands  ;  b,  upper  coronary  glands ;  c,  paracardial  glands ; 
d,  outlying  glands  of  left  suprapancreatic  group  :  e,  right  gastro-epiploic 
glands  ; /,  subpyloric  glands;  g,  suprapyloric  gland. 

efferents  from  the  suprapancreatic  glands  pass  to  the  receptaculum 
chyli  and  communicate  freely  with  the  superior  mesenteric  glands. 

3.  The  right  gastro-epiploic  group  of  glands  lie  below  the  artery 
of  the  same  name.  They  are  from  four  to  seven  in  number,  and  rarely 
extend  to  the  left  farther  than  the  middle  of  the  greater  curvature, 
though  they  have  a  tendency  to  stray  downwards  between  the  layers 
of  the  great  omentum.  The  vessels  from  these  glands  pass  to  the 
subpyloric  group. 

4.  The  subpyloric  glands  are  situated  to  the  right  of  the  pylorus, 
in  the  angle  between  the  first  and  second  parts  of  the  duodenum, 
in  front  of  the  head  of  the  pancreas  and  in  close  relation  to  the 
bifurcation  of  the  gastro-duodenal  artery.  They  receive  lymphatic- 
vessels  from  the  pylorus  and  duodenum  and  the  efferent  vessels  from 
the  right  gastro-epiploic  glands.  Their  efferents  pass  to  the  supra- 
pancreatic and  superior  mesenteric  glands. 


3Q2  THE   STOMACH   AND   DUODENUM 

The  stomach  is  divided  into  three  lymphatic  areas,  viz.  the  lesser 
curvature,  the  greater  curvature,  and  the  fundus.  The  lymphatics 
from  the  lesser  curvature  and  its  immediate  neighbourhood  pass  into 
the  lower  coronary  group  of  glands.  Occasionally  a  vessel  passes  by 
this  group  to  end  in  the  upper  coronary  set  (Fig.  387,  p.  382).  In 
addition,  vessels  from  the  upper  part  of  the  pyloric  canal  run  upwards 
into  the  lesser  omentum,  sometimes  into  one  or  two  suprapyloric 
glands  whose  efferents  with  the  uninterrupted  vessels  pass  downwards 
to  end  in  the  right  suprapancreatic  glands.  Occasionally  a  vessel 
passes  behind  the  duodenum  to  end  in  a  gland  behind  the  pancreas 
close  to  the  common  bile-duct. 

The  vessels  from  the  fundus  close  to  the  cardia  pass  to  the  para- 
cardial glands,  and  thence  to  the  upper  coronary  set.  Those  from 
the  remainder  of  the  fundus  down  to  a  point  in  the  greater  curvature 
immediately  below  the  oesophagus  pass  to  the  splenic  glands.  The 
right  portion  of  the  greater  curvature  drains  into  the  right  gastro- 
epiploic glands. 

Nerves  of  the  stomach. — The  stomach  receives  fibres  from 
both  vagi  and  also  through  the  solar  plexuses  from  the  7th,  8th, 
and  9th  dorsal  nerves. 

Bacteriology. — According  to  Miller  and  to  Harvey  Gushing, 
the  healthy  stomach,  when  empty,  contains  no  micro-organisms. 
In  the  duodenum  the  number  of  micro-organisms  is  small,  but  they 
become  more  numerous  lower  down  in  the  intestine.  This  is  in  accord- 
ance with  surgical  experience.  Operations  upon  the  alimentary  canal 
in  the  upper  abdomen  as  a  whole  have  a  lower  death-rate  than  those 
in  the  lower. 

These  facts  are  of  the  utmost  surgical  importance.  It  is  possible 
to  render  the  stomach  and  upper  part  of  the  small  intestine  sterile, 
and  thus  to  lessen  the  danger  of  extensive  operations  in  this  region, 
in  cases  in  which  there  is  no  obstruction.  If,  however,  the  stomach 
and  duodenum  are  prevented  from  emptying  themselves,  their  contents 
teem  with  organisms. 

Clinical  examination. — In  the  investigation  of  suspected 
disease  the  history  should  be  taken  with  the  greatest  care,  and  the 
patient  allowed,  as  far  as  possible,  to  tell  his  own  tale,  being  guided 
skilfully  along  the  necessary  channels.  It  is  important  to  elicit  the 
initial  symptom,  the  first  alteration  from  normal  which  attracted 
the  attention  of  the  patient.  Was  the  onset  sudden  or  gradual  ? 
In  some  cases,  pain  is  the  first  and  most  important  symptom  through- 
out, both  in  acute  and  in  chronic  cases  ;  in  others,  the  sudden  vomiting 
of  a  large  quantity  of  blood  when  in  apparent  health,  the  passage  of 
blood  by  the  rectum,  loss  of  appetite,  or  a  continuous  and  inexplicable 
loss  of  weight,  or  anaemia.     In  a  few  of  the  cases  of  perforation  of  a 


VISCERAL  FAIN  303 

trie  or  duodenal  ulcer,  the  sudden  onset  of  symptoms  of  an  abdo- 
minal catastrophe  is  the  first  indication  of  alimentary  disease. 

The  course  of  the  disease  must  be  as  carefully  investigated,  and 
the  occurrence  of  complications  inquired  for.  In  some  cases,  par- 
ticularly in  chronic  ulcers  of  the  duodenum,  and  less  often  in  chronic 
gastric  ulcers,  the  symptoms  intermit  ami  there  are  periods  of  perfect 

health. 

It  must  never  be  forgotten  that  "  dyspepsia  "  may  be  caused 
by  disease  of  neighbouring  organs,  particularly  the  gall-bladder  and 
bile-ducts,  and  appendix,  by  direct  involvement  or  reflexly.  It  should 
also  be  remembered  that  although  for  anatomical  reasons  the  diges- 
tive tract  is  split  up  into  separately  named  portions,  physiologically 
it  is  a  whole,  each  part  of  which  is  dependent  for  its  efficient  working 
on  the  health  of  the  others.  Hedblom  and  Cannon  have  shown 
experimentally  on  cats  that  irritation  of  the  colon  or  csecum  retards 
the  discharge  of  food  from  the  stomach. 

Pain  and  tenderness. — It  is  universal  knowledge  that  pain  in 
the  epigastric  region  after  food  is  a  symptom  of  interference  with  the 
normal  functions  of  the  stomach.  The  causation  of  this  pain  in 
disease  of  the  stomach  and  duodenum,  however,  is  a  matter  for  dis- 
cussion. Considerable  research  on  the  sensibility  of  the  viscera  has 
been  carried  out  since  Lennander's  pioneer  work  appeared  in  1901.  The 
stomach  and  intestines  are  insensitive  to  those  stimuli  which  cause 
pain  when  applied  to  the  surface  of  the  body  ;  they  can  be  cut  or 
burnt  without  the  patient  evincing  any  sign  of  discomfort.  It  is 
evident,  therefore,  that  the  afferent  nerves  of  the  stomach  require 
for  their  excitation  stimuli  different  from  those  of  the  skin.  The 
parietal  peritoneum  was  considered  by  Lennander  to  be  sensitive  ; 
this  has  been  shown  by  Ramstrom  to  be  due  to  the  rich  plexus  of 
nerves  in  the  subserous  tissue.  These  nerves  are  branches  of  those 
which  supply  the  muscles  ot  the  abdominal  wall,  and  are  beset  with 
Pacinian  corpuscles.  The  sensibility  of  this  layer  is  that  form  named 
by  Head  and  the  present  writer  "  deep." 

According  to  Lennander  and  his  followers,  visceral  pain  is  due 
in  all  cases  to  stimulation  of  the  parietal  peritoneum  as  the  result  of 
direct  pressure,  traction  upon  mesenteries,  or  inflammation.  That 
other  factors  must  come  into  play  is  evident.  The  most  severe  ab- 
dominal pain  is  associated  with  irregular  muscular  contractions  in 
hollow  organs,  due  to  irritation  or  obstruction  (colic).  In  these  cases 
it  is  difficult  to  believe  that  it  is  due  to  pressure  on  the  parietal 
peritoneum  or  traction  on  mesenteries,  and  observation  upon  ex- 
posed portions  of  intestine  in  breaches  of  surface  of  the  abdominal 
|1  has  proved  this  view  to  be  incorrect. 

Henry  Head  and  the  present  writer  showed  that  ice-water  and 


304  THE   STOMACH  AND   DUODENUM 

water  at  50°  C,  introduced  directly  through  gastrostomy  or  colos- 
tomy openings,  gave  rise  to  sensations  of  cold  and  warmth.  We 
considered  this  showed  that  the  sensibility  of  the  viscera  resembled 
protopathic  sensibility  elsewhere.  The  sensation  produced  was  never 
localized  inside  the  abdomen,  but  usually  in  the  umbilical  region. 
James  Mackenzie  does  not  accept  these  conclusions,  and  explains  the 
feeling  of  cold  as  due  to  vaso-constriction  in  the  vessels  of  the  skin  of 
the  abdomen  reflexly  produced.  Hertz  came  to  the  conclusion  that 
"  the  oesophagus  and  anal  canal  are  almost  always  sensitive  to  heat  and 
cold,  the  stomach  rarely  if  ever,  and  the  colon  to  a  limited  extent 
in  a  very  small  number  of  cases."  Whatever  the  explanation  of  the 
recognition  of  ice  and  hot  water,  most  of  the  pain  complained  of  in 
diseases  of  the  organs  with  which  we  are  dealing  is  reflected  and  not 
direct. ' 

Pain  resulting  from  disease  of  the  stomach  is  most  often  com- 
plained of  in  the  epigastric  region,  particularly  on  the  left  side,  also 
posteriorly  at  the  lower  angle  of  the  left  scapula.  It  is  frequently 
associated  with  tenderness  (hyperalgesia),  both  superficial  (cutaneous) 
and  deep,  and  with  increase  of  reflexes  or  muscular  rigidity. 

Cutaneous  hyperalgesia  is  occasionally  met  with.  Its  exact  surgical 
significance  is  unknown.  It  is  most  often  associated  with  ulcer  of 
the  stomach  in  women,  rarely  in  men,  and  has  also  been  observed  in 
cases  of  hsemorrhagic  gastritis.  Usually  left-sided,  it  may  extend  as  a 
band  around  the  body  in  the  region  of  the  7th,  8th,  and  9th  thoracic 
segments,  or  be  present  only  in  front  or  behind.  It  is  certainly  absent 
in  perforation  of  the  stomach  or  duodenum. 

Following  Head,  it  has  been  the  teaching  at  the  London  Hospital 
that  the  presence  of  deep  tenderness  indicates  an  affection  of  the  peri- 
toneum. Although  deep  tenderness  is  seen  in  its  most  exquisite 
form  in  cases  of  recent  perforative  peritonitis,  marked  deep  tenderness 
is  often  present  without  peritonitis.  The  muscular  and  sut 
lavors  of  the  abdominal  wall  are  supplied  from  the  sguMiivs. 
and  the  writer  have  shown  that  the  afferent  fibres 
nerves,  when  stimulated  as  the  result  of  pressure,"  cause"^ 
the  painful  contractions  of  muscles  are  also  well  known, 
that  deep  tenderness  is  often  "  reflected  "  ;  but  in  perit* 
nerves  themselves  are  directly  affected  by  the  inflammati^ 
parietal  peritoneum.  Stimulation  of  these  nerves  subser 
sensibility  is  the  cause  of  the  widespread  muscular  rigidity 
peritonitis. 

The  localized  rigidity  which  may  be  manifest  in  a  segment  of  the 
rectus  in  many  cases  of  stomach  disease  is  due  to  increased  briskness 
of  the  reflex,  and  does  not  indicate  peritonitis.  It  is  no?  present  on 
gentle  handling,  and  is  associated  with  deep  tenderness  ;   on  the  other 


CLINICAL    EXAM  I N  ATIONS 

hand,  the  rigidity  accompanying  the  deep  tenderness  in  peritonitis 
is  permanent  and  will  be  felt  with  the  gentlest  Jiami lin lt. 

To  recapitulate,  pain  and  hyperalgesia,  both  superficial  and  deep, 
and  muscular  rigidity,  in  disease  of  the  stomach  and  duodenum  on- 
;;♦•<  ompanied  by  peritoneal  irritation,  are  reflex,  due  to  the  heightened 
excitability  of  certain  segments  of  the  spinal  cord  receiving  abnormal 
impulses  from  the  affected  viscns. 

The   important   points  to   elicit   with   regard    to   the    pain    are — 

(1)  Its  character,  position,  and  spread.  (2)  Its  relation  to  food  ; 
the  time  at  which  it  appears;  does  it  waken  the  patient  at  night  '< 

(3)  Is  it  relieved  by  vomiting,  or  by  taking  food,  drugs,  or   fluid  ? 

(4)  Is  it  accompanied  by  or  relieved  by  flatulence  ? 
Vomiting.— Vomiting  is  nearly  always  met  with  during  the  course 

of  any  surgical  disease  of  the  stomach  or  duodenum.  But,  while 
rarely  absent  at  some  time  during  the  course  of  gastric  disease,  it 
is  only  present  as  a  late  complication  in  certain  diseases  of  the 
duodenum. 

The    important    points    to    investigate    are — (1)    Its    frequency. 

(2)  Its  relation  to  food.  (3)  Does  it  relieve  pain  ?  (4)  Its  colour, 
odour,  etc.     (5)  Does  it  contain  blood  ? 

(See  also  under  Examination  of  the  Vomit,  p.  310.) 

Haemorrhage. — Bleeding  more  or  less  severe  probably  occurs  in 
all  diseases  accompanied  by  a  breach  of  surface  of  the  mucous  mem- 
brane. Blood  may  be  vomited  (hsematemesis)  or  passed  per  rectum 
(melsena).  If  a  large  amount  is  poured  out  it  may  be  vomited  at 
once  and  is  easily  recognized ;  if  poured  out  in  small  quantity  it  is 
altered  in  colour  and  becomes  coagulated  in  tiny  brownish-red  masses 
resembling  coffee-grounds.  Death  may  result  before  the  appearance  of 
any  blood  externally,  but  this  is  very  unusual.  Wliile  the  presence 
of  any  large  amount  of  blood  is  obvious,  smaller  amounts  should  not 
be  overlooked,  for  their  importance  is  great. 

Appetite. — Information  with  regard  to  appetite  is  important. 
In  some  cases  of  carcinoma  of  the  stomach,  loss  of  appetite  or 
repugnance  to  the  sight  of  food  is  the  first  sign  of  the  disease.  In 
duodenal  ulcer  the  appetite  may  be  good  and  the  patient  may  say 
that  he  eats  more  during  the  attack  of  pain  than  at  any  other  time  ; 
or,  as  in  some  cases  of  gastric  ulcer,  the  appetite  is  good,  but  fear 
of  the  consequent  pain  restrains  the  patient  from  satisfying  it. 

Jaundice. — This  is  a  rare  complication  and  arises  as  the  resull 
of  obstruction  to  the  biliary  passages  from  pressure  or  involvement 
in  new  growth,  adhesions  or  contraction  of  an  ulcer,  or  direct  spread 
from  the  duodenum.  It  is  more  often  met  with  in  diseases  of  the 
duodenum  than  in  diseases  of  the  stomach,  where  it  is  usually  a 
late  result  of  carcinoma.     It  may  be  an  important  symptom  in  the 


306  THE   STOMACH  AND   DUODENUM 

differential  diagnosis  between  affections  of  the  gall-bladder  and  those  of 
the  stomach  or  duodenum. 

Physical  examination. — Special  examinations  are  necessary 
in  many  cases  of  stomach  disease.  These  should  not  supersede  the 
routine  methods  employed  to  investigate  disease  in  other  parts  of 
the  abdomen. 

The  age  and  general  appearance  of  the  patient  must  be  taken 
into  consideration.  The  condition  of  the  teeth  must  be  carefully 
looked  to  ;  it  may  be  found  that  the  symptoms  can  be  accounted  for 
on  dental  grounds,  but  in  any  case  no  operation  on  the  stomach  or 
intestines  should  be  done,  unless  in  an  emergency,  until  septic  stumps 
have  been  removed  and  the  mouth  rendered  as  sterile  as  possible. 

For  the  physical  examination  the  patient  should  be  lying  com- 
fortably on  a  couch  with  the  shoulders  a  little  raised  ;  the  whole  of 
the  abdomen  and  the  lower  part  of  the  thorax  must  be  uncovered, 
for  many  tumours  have  been  overlooked  through  neglecting  this 
precaution. 

The  hand  should  never  be  placed  on  the  abdomen  until  inspection 
has  been  thorough.  Note  should  be  made  of  the  general  condition 
of  the  abdomen  and  of  obvious  signs  of  tumour,  localized  bulgings, 
visible  peristalsis,  skin  cracks,  etc. ;  then  special  attention  directed 
to  the  epigastric  and  left  hypochondriac  regions,  where  tumours  may 
be  seen  descending  on  respiration  which  cannot  be  detected  in  any 
other  way.  The  narrow  upper  abdomen  so  often  present  in  enteroptosis 
should  not  be  overlooked.  In  many  cases  it  is  associated  with  a 
floating  tenth  rib,  which  Stiller  considers  a  stigma  of  gastric  neurosis. 

Palpation  should  first  be  directed  towards  eliciting  the  presence 
of  areas  of  tenderness,  superficial  or  deep,  or  of  muscular  rigidity. 
Search  must  then  be  made  for  a  tumour ;  its  position,  mobility,  and 
respiratory  movement  must  be  investigated,  and,  when  doubt  exists, 
re-examined  after  inflation  of  the  stomach  and  occasionally  the  colon 
(p.  308).  Splashing  may  be  obtained,  but  is  only  of  importance 
when  found  in  districts  other  than  those  occupied  by  the  normal 
stomach  or  when  occurring  more  than  three  hours  after  a  meal.  Peri* 
stalsis  may  sometimes  be  elicited  by  gently  nicking  the  abdomen. 
The  size  of  the  liver  should  be  noted.  The  right  kidney  should  always 
be  examined,  and  if  there  is  any  suspicion  of  gastroptosis  the  patient 
should  be  seen  in  the  erect  position. 

The  supraclavicular  region  on  the  left  side  must  be  palpated  for 
evidence  of  glandular  enlargement. 

Percussion  and  auscultation. — It  may  be  possible  to  mark  out 
by  percussion  the  position  of  the  greater  curvature,  but  it  is  occasion- 
ally difficult  to  distinguish  between  the  note  given  by  the  colon  and 
that  given  by  the  stomach.     Percussion  must  be  light  and  should  be 


PERCISSION-Al  SCILTATION    OF    STOMACH 
systematically  done  Erom   l>el<>w  upwards.    The  lower  bordei  of  the 

normal  stomal  li  does  not    reach  the  umbilicus.      It  is  possible  to  mark 

out  by  percussion  the  adjacenl  areas  ol  liver  ami  Long,  but  tin-  is  of 
little  importance  in  disease  of  the  stomach.     The  abdomen  should  be 
percussed  for  evidence  of  free  fluid  ;    but  a  considerable  amount  m 
be  present  without  any  marked  increase  of  dullness  being  perceptible 
in  the  flanks. 

Auseult  at  ion -percussion  often  gives  more  aid  thai;  percussion 
alone.  The  stethoscope  is  placed  about  the  centre  of  the  gastric  area, 
and  light  scratching  movements  are  made  on  the  abdominal  wall, 
beginning  near  the  stethoscope  and  working  outwards;  as  soon  as 
the  borders  of  the  stomach  are  reached  the  sounds  change  in  character. 
Hertz  in  his  recent  investigations  has  found  that  the  area  so  obtained 
did  not  show  any  resemblance  to  the  true  shape  of  the  stomach  as 
seen  by  X-ray  examination  after  a  bismuth  meal. 

Auscultation  alone  may  detect  bubbling  sounds  or  friction.  It 
has  been  stated  that  delay  in  the  time  occupied  in  the  passage  of  food 
from  the  mouth  to  the  stomach  may  be  of  diagnostic  importance  in 
early  cases  of  carcinoma  or  obstruction  at  the  cardiac  end  of  the 
stomach.  Hertz  has  recently  investigated  this  with  the  aid  of  X-rays, 
and  has  come  to  the  conclusion  that  great  variation  exists  in  the  time 
at  which  the  sound  is  heard.  It  was  formerly  considered  due  to  the 
food  entering  the  stomach,  but  Hertz  has  shown  that  it  does  not  occur 
until  the  oesophagus  is  empty.  It  can  usually  be  heard  about  four 
seconds  after  swallowing,  but  may  be  delayed  as  long  as  ten  seconds  in 
normal  individuals,  so  that  little  reliance  can  be  placed  upon  it  as  a 
diagnostic  sign. 

When  the  symptoms  are  indefinite,  examination  must  be  made 
for  signs  of  tabes.  Cases  have  been  recorded  in  which  gastric  crises 
were  treated  by  gastrojejunostomy. 

There  are  five  special  methods  of  examination  which 
are  of  use — (1)  Illumination  and  examination  of  the  stomach. 
(2)  Inflation  of  the  stomach.  (3)  X-ray  examination.  (4)  Examina- 
tion of  stomach  contents.     (5)  Examination  of  faeces. 

1.  Illumination. — It  seems  that  the  difficult  problem  of  inspection 
of  the  interior  of  the  stomach  by  means  of  an  instrument  passed  by 
the  mouth  will  shortly  be  solved. 

Many  attempts  have  been  made  since  the  introduction  of  the 
cystoscope  to  perfect  an  instrument  with  which  the  stomach  could 
be  similarly  examined.  Mikulicz  in  1881  appears  to  have  been  the 
first  to  use  the  gastroscope  which  was  constructed  by  Leiter  with 
his  help.  The  great  difficulties  of  construction  and  of  introduction 
prevented  its  general  use,  and  intragastric  examination  remained  in 
abeyance  until  the  adoption  of  direct  examination  of  the  oesophagus 


308  THE   STOMACH   AND    DUODENUM 

and  trachea  stimulated  to  further  research.  Chevalier  Jackson  of 
Pittsburg  introduced  in  1907  the  direct  examination  of  the  stomach 
through  a  straight  tube,  and  by  its  means  has  diagnosed  many  surgical 
conditions. 

The  Souttar-Thompson  gastroscope  was  a  great  advance  and 
showed  that  the  greater  part  of  the  stomach  could  be  investigated  by 
indirect  vision.  I  believe,  however,  that  the  use  of  an  indirect-vision 
gastroscope  of  this  type  is  more  dangerous  than  exploratory  laparotomy 
in  the  hands  of  a  competent  surgeon. 

The  Hill-Herschell  gastroscope,  which  combines  both  direct  and 
indirect  methods,  is  a  great  improvement,  and  has  already  been  used 
with  success  in  the  differential  diagnosis  between  multiple  hemorrhagic 
erosions  and  chronic  ulceration. 

2.  Inflation. — -Inflation  with  air  is  useful  in  the  diagnosis  of 
gastroptosis,  dilated  stomach,  or  hour-glass  stomach,  and  in  showing 
the  relationship  of  certain  tumours  to  the  stomach.  In  the  latter 
case  dilatation  of  the  colon  is  sometimes  also  employed. 

This  method  was  first  adopted  in  England  by  Samuel  Fenwick. 
It  must  be  used  with  care  in  selected  cases,  and  never  employed  when 
evidence  of  active  ulceration  is  present.  Fatal  accidents  after  inflation 
have  occurred  from  rupture  of  the  stomach  and  from  haematemesis 
in  cases  with  active  disease. 

The  stomach  may  be  inflated  in  two  ways — with  air  through  a 
stomach-tube  to  which  a  Higginson  syringe  is  attached,  or  by  C02 
evolved  from  the  intragastric  mixing  of  tartaric  acid  and  sodium 
bicarbonate.  The  former  method  is  the  more  accurate,  and  is  abso- 
lutely under  the  control  of  the  observer,  its  only  disadvantage  being 
that  it  involves  the  passage  of  a  stomach-tube.  It  should  be  used  in 
all  cases  in  which  the  patient  permits  this  manoeuvre.  On  the  other 
hand,  inflation  with  C02  is  easier  and  involves  less  manipulation.  A 
little  less  than  a  teaspoonful  of  tartaric  acid  dissolved  in  about  2  oz. 
of  water  is  administered  ;  a  teaspoonful  of  bicarbonate  of  soda 
dissolved  in  half  a  tumbler  of  water  is  then  given  slowly  until  the 
desired  degree  of  inflation  is  reached.  The  outline  of  the  stomach 
in  many  cases  becomes  visible,  or  is  easily  mapped  out  by  light 
percussion. 

3.  X-ray  examination. — Examination  of  the  stomach  by  means 
of  a  screen  after  the  ingestion  of  a  bismuth  meal  is  of  aid  in  the 
diagnosis  of  obscure  cases,  and  may  demonstrate  the  shape,  size,  and 
position  of  the  viscus,  the  presence  of  gastroptosis,  dilatation,  hour- 
glass deformity,  or  cardiac  stricture.     (Fig.  364.) 

From  1  to  2  oz.  of  bismuth  carbonate  is  given  in  bread-and-milk 
or  arrowroot,  and  the  patient  screened  at  intervals  according  to  the 
nature  of  the  case. 


TESTS  FOR   GASTRIC   ACIDITY  309 

4.  Examination  of  stomach  contents.  -Chemical  examination 
of  the  contents  of  the  stomach  should  be  made  in  every  case,  and  the 
amounts  of  total  and  free  I [(  I  estimated.  The  contents  of  t  he  stomach 
should  be  obtained  by  means  of  the  Btomach-tube  after  a  test  meal. 
Examination  of  the  vomit,  useful  for  certain  purposes,  does  not  supply 
the  necessary  information  (p.   310). 

Attempts  have  been  made  to  estimate  the  motor  power  of  the 
stomach,  apart  from  examination  of  the  stomach  contents,  after  a 


Fig.  364. — Radiograph  of   an  hour-glass  stomach  after  a 
bismuth  meal.     (Schall.) 

test  meal.  The  salol  test  of  Ewald  is  based  upon  the  fact  that  salol 
is  decomposed  into  carbolic  and  salicylic  acids  in  an  alkaline  medium, 
the  latter  appearing  in  the  urine  as  salicyluric  acid  normally  in  about 
an  hour.  The  test  is  not  altogether  reliable,  as  the  salol  may  be 
decomposed  in  the  stomach  owing  to  the  presence  of  alkaline  mucus, 
or  delayed  in  the  intestine  owing  to  acid  fermentation.  A  similar 
test  is  made  with  iodipin.  One  gram  of  iodipin  is  given  in  a  capsule 
immediately  after  a  meal ;  normally,  iodine  can  be  detected  in  the 
saliva  in  forty-five  minutes.  Attempts  have  also  been  made  to  estimate 
the  acidity  of  the  gastric  contents  without  the  passage  of  the  stomach* 
tube.  In  Giinzburg's  method  a  tablet  of  0-2  grm.  of  potassium  iodide 
is  inserted  into  a  thin  rubber  tube,  the  ends  folded,  and  the  packet 


3io  THE   STOMACH  AND   DUODENUM 

tied  with  three  threads  of  fibrin  hardened  in  alcohol.  One  is  swallowed 
three-quarters  of  an  hour  after  an  Ewald  test  meal,  and  the  saliva 
tested  for  KI  at  intervals  of  fifteen  minutes  till  the  reaction  is  obtained, 
normally  in  an  hour  to  an  hour  and  a  quarter. 

Another  test  of  a  similar  character  is  the  "  desmoid  "  test  of  Sahli. 
It  is  based  on  the  assumption  that  catgut  in  the  raw  state  is  soluble 
in  the  stomach.  A  pill  is  made  of  0-5  grm.  of  methylene  blue  and 
enclosed  in  a  rubber  sac  made  by  twisting  up  the  pill  in  a  thin  piece 
of  rubber  tissue  and  tying  the  neck  with  thin  catgut.  The  pill  is  given 
with  or  just  after  the  midday  meal,  and  the  urine  examined  five, 
seven,  and  eighteen  or  twenty  hours  after.  Its  excretion  is  recognized 
by  the  bluish  colour  given  to  the  urine.  If  this  be  absent,  the  chromogen 
alone  may  be  occasionally  though  rarely  present ;  it  may  be  demon- 
strated by  the  appearance  of  a  greenish-blue  colour  when  the  urine 
is  boiled  with  one-fifth  its  volume  of  glacial  acetic  acid.  If  it  be  found 
within  eighteen  or  twenty  hours  the  test  is  called  positive.  Opinions 
differ  as  to  the  value  of  these  tests  ;  the  information  obtained  is 
approximate  only  ;  they  should  not  be  used  when  it  is  possible  to 
give  a  test  meal. 

The  fasting  stomach  should  be  empty  or  nearly  so.  Motor  in- 
sufficiency is  present  if,  on  the  morning  after  a  light  evening  meal, 
or  six  hours  after  a  test  meal  (Leube)  of  a  quarter  of  a  pound  of 
minced  meat  and  bread,  food  can  still  be  extracted  from  the  stomach 
by  the  tube. 

After  the  stomach-tube  has  been  passed  in  the  morning  in  the 
fasting  stomach,  Ewald's  test  breakfast  (a  slice  of  stale  bread  or 
toast  and  a  pint  of  weak  tea)  should  be  given,  following  gastric  lavage 
if  necessary.  It  is  withdrawn  by  the  stomach-tube  an  hour  later. 
The  general  appearance  is  noted,  and  total  acidity  and  free  HC1 
estimated. 

Examination  of  the  vomit. — The  quantity  vomited  should  be  noted 
as  an  indication  of  dilated  stomach,  as  also  the  characteristic  yeasty 
smell,  and  presence  of  food  known  to  have  been  taken  by  the  patient 
some  days  previously.  The  presence  of  blood  in  large  quantities  is 
obvious  ;  in  smaller  quantities  it  may  be  difficult  to  discover  or  may 
demonstrate  itself  as  coffee-grounds  vomit.  The  presence  of  traces 
of  blood  may  be  proved  by  the  detection  of  hsemin  crystals,  by  spectro- 
scopic examination,  or  by  the  benzidin  test.  Pus  is  occasionally  found 
in  the  vomit  from  communication  with  an  empyema  of  the  gall-bladder, 
rupture  of  an  abscess  of  the  gastric  wall,  or  of  a  perigastric  abscess  into 
the  stomach  cavity.  The  presence  of  bile  in  the  vomit  is  important 
in  cases  of  duodenal  stricture  and  in  regurgitant  vomiting  following 
gastroenterostomy  ;    it  is  detected  by  Gmelin's  test. 

Faecal  vomit  is  found  in  cases  of  gastro-colic  fistula. 


MALFORMATIONS    AM)    MISPLACEMENTS       311 

Microscopical  examination  of  the  vomit  may  reveal,  in  addition 
to  fragments  of  undigested  food,  various  micro-organisms.  The 
most  important  are  the  Oppler-Boas  bacillus,  sarcinse,  and  yeast  fungi. 
These  arc  usually  found  in  cases  of  dilatation  of  the  stomach.  The 
Oppler-Boas  bacillus  is  said  to  be  constantly  present  in  advanced  cases 
of  cancel  of  the  stomach,  and  is  a  cause  of  lactic-acid  fermentation; 
it  is  usually  absent  in  non-malignant  disease  of  the  stomach.  It  is 
a  long,  non-motile  bacillus,  frequently  joined  end  to  end  to  form 
threads. 

Sarcinse  occur  in  the  form  of  colonies  of  cocci  arranged  in  squares, 
said  to  resemble  bales  of  cotton  ;  they  are  rarely  found  in  'advanced 
cases  of  carcinoma  of  the  stomach. 

5.  Examination  of  the  faeces. — After  the  exclusion  of  other 
causes  of  haemorrhage,  especially  haemorrhoids,  the  discovery  of  occult 
blood  in  the  faeces  may  be  useful  in  the  diagnosis  of  duodenal  ulcer 
and  of  cancer  of  the  stomach.  It  may  be  recognized  spectroscopically, 
by  the  formation  of  haemin  crystals,  or  by  Adler's  benzidin  test.  Extreme 
care  in  preliminary  dieting  is  unnecessary,  as  well-cooked  meat  does 
not  interfere  with  the  test.  (For  methods  of  examination,  the 
reader  is  referred  to  Hutchison  and  Rainy's  "  Clinical  Methods," 
5th  edition,  1912.) 

MALFORMATIONS   AND  MISPLACEMENTS,   ETC. 

Congenital  malformations  and  misplacements  of  the  stomach  and 
duodenum  are  rare.  Stenosis  may  occur  at  the  pylorus,  in  the  de- 
scending portion  of  the  duodenum,  or  at  the  junction  of  the  cardiac 
and  pyloric  portions  of  the  stomach  (congenital  hour-glass  stomach) ; 
occasionally  diverticuli  are  present. 

Acquired  malformations  almost  invariably  result  from  contraction 
of  fibrous  tissue  or  from  new  growth. 

Congenital  misplacement  may  be  present  in  situs  transversus  or 
in  hernia,  while  the  acquired  variety  may  be  part  of  a  generalized 
enteroptosis  or  may  occur  as  the  rare  volvulus. 

CONGENITAL  ATRESIA  OF  THE  PYLORUS 

Cases  have  been  described  in  which  the  pyloric  end  of  the  stomach 
terminated  blindly,  or  in  which  only  an  exceedingly  fine  communication 
existed  between  the  stomach  and  the  first  part  of  the  duodenum. 
In  these  cases  no  thickening  is  found  around  the  pylorus.  In  all  the 
recorded  instances  the  disease  has  run  a  rapidly  fatal  course.  Frequent 
vomiting  from  birth  should  direct  attention  to  the  possibility  of  this 
condition.  Hitherto  no  case  has  been  diagnosed.  Gastro-duoden- 
ostomy  or  gastrojejunostomy  should  be  performed. 


3i2  THE   STOMACH   AND   DUODENUM 

CONGENITAL   STRICTURE   AND    OCCLUSION   OF   THE 
DUODENUM 

These  are  rare  conditions.  Out  of  13  cases  of  congenital  occlusion  or 
stenosis  of  the  intestines  (other  than  those  in  connexion  with  the  rectum) 
collected  by  Barnard  from  the  records  of  the  London  Hospital,  in  no  instance 
was  the  duodenum  affected. 

Out  of  185  cases  of  congenital  occlusion  of  the  intestines  collected  by 
Kuliga,  46  were  of  the  duodenum.  Schlegel,  quoted  by  Braun,  states  that 
occlusion  occurs  in  the  duodenum  in  32*5  per  cent,  of  the  cases. 

There  may  be  a  septum,  with  or  without  a  perforation  in  its  centre, 
running  across  the  bowel,  composed  of  the  muscular  as  well  as  of  the 
mucous  and  submucous  coats.  The  interruption  of  the  duodenum 
may  be  complete. 

Common  bile  duct. 


Pyloru 


Fig.  365. — Congenital  occlusion  of  duodenum,  in  a  child 
a  few  days  old.     {Roc  and  Shaw's  case) 

(Royal  College  of  Surgeons  Museum.) 

The  occlusion  is  usually  situated  in  the  region  of  the  ampulla  of 
Vater  (Fig.  365),  and  is  in  many  cases  associated  with  malformations 
of  other  structures.  Occlusion  is  more  common  than  stenosis  ;  in 
57  cases  collected  by  Cordes,  it  was  present  in  48. 

Occlusion  or  stenosis  is  occasionally  present  at  the  junction  of 
the  duodenum  and  jejunum  (5  out  of  57  cases,  Cordes). 

As  a  rule,  vomiting  occurs  soon  after  birth,  its  character  depending 
on  the  position  of  the  atresia  or  stenosis,  but  in  the  case  of  stenosis 
the  symptoms  may  be  delayed,  one  case  having  been  recorded  in  a 
girl  of  13  (Shaw  and  Baldauf). 

Treatment. — If  the  condition  is  recognized,  gastrojejunostomy 
offers  the  only  hope  of  saving  life. 

ACQUIRED    STRICTURE    OF    THE    DUODENUM 

This  condition  is  usually  the  result  of  chronic  ulceration,  and 
in  the  later  stages  may  bring  about  dilatation  of  the  stomach.  A 
stricture  may  also  result  from  affections  of  the  pancreas,  or  from 
adhesions  due  to  gall-stones. 


DUODENAL   STRICTURE  3'3 

The  superior  mesenteric  vessels  crossing  the  third  portion  of  the 
duodenum  have  been  credited  with  the  causation  of  duodenal  obstruc- 
tion (p.  324).  Hour-glass  duodenum  has  been  recorded  as  a  late 
result  of  duodena]  ulcer. 

Symptoms  of  duodenal  stenosis. — The  disease  is  usually 
chronic  :  when  produced  by  pressure  of  vessels  or  lodgment  of  a 
gall-stone  it  may  be  acute 

The  chronic  forms  must  be  divided  into  two  groups — those  in  which 
the  stenosis  is  above,  and  those  in  which  it  is  below,  the  entrance  of 
the  common  bile-duet.  The  diagnosis  of  the  former,  which  is  the 
more  common,  has  never  been  made  before  operation,  as  the  symptoms 
are  identical  with  those  of  stenosis  of  the  pylorus  ;  but  X-ray  examina- 
tion after  a  bismuth  meal  might  possibly  reveal  its  seat.  When  the 
stricture  is  below  the  entrance  of  the  common  bile-duct  the  symptoms 
are  characteristic  :  there  is  dilatation  of  both  the  stomach  and  the 
duodenum,  and  bile  and  pancreatic  juices  pass  readily  into  the  stomach 
and  are  vomited.  The  reaction  of  the  gastric  contents  is  neutral  or 
alkaline.     The  motions  may  be  colourless,  or  nearly  so. 

Treatment. — Stricture  of  the  duodenum  should  be  treated  so 
as  to  restore  as  far  as  possible  the  normal  condition  of  parts  either 
by  duodenoplasty  or  by  Finney's  operation  (p.  418).  Where  this  is 
impossible  from  the  presence  of  adhesions,  or  inadvisable  from  the 
presence  of  an  ulcer,  posterior  gastrojejunostomy  should  be  performed, 
as  near  the  pylorus  as  possible. 

GASTRIC   DIVERTICULA 

These  are  rare,  and  usually  arise  as  the  result  of  gastric  ulcer, 
rarely  of  carcinoma.  They  belong  to  the  "  traction  :'  group  of  diver- 
ticula, and  are  the  result  of  the  adhesion  of  the  stomach  to  the 
abdominal  wall,  liver,  or  pancreas. 

Diagnosis  is  usually  impossible.  If  the  pouch  is  so  shaped 
or  situated  as  to  permit  lodgment  of  food,  it  may  cause  symptoms 
due  to  its  distension  or  inflammation.  This  condition  usually  occurs 
in  women,  and  should  be  thought  of  when,  with  stomach  symptoms 
in  a  woman,  there  is  a  tumour  adherent  to  the  abdominal  wall  in  the 
left  epigastric  region. 

Treatment  should  consist  of  excision  of  the  diverticulum, 
accompanied  by  gastro-enterostomy  if  necessary. 

Two  cases  are  recorded,  in  both  of  which  the  patients  recovered 
after  operation  (Kolaczek,  Silbermark). 

DUODENAL   DIVERTICULA 

Diverticula  of  the  duodenum  are  usually  situated  close  to  the  biliary 
papilla,  are  small  and  formed  of  the  mucous  coat  only  (Fig.  366). 


3H 


THE  STOMACH  AND  DUODENUM 


They  were  held  by  Letulle  to  be  a  congenital  abnormality,  but  are 
now  usually  considered  to  be  acquired.  Arthur  Keith  states  that 
they  are  not  uncommon  in  old  people,  especially  in  those  who  are 
the  subjects  of  enteroptosis.  In  3  of  the  12  cases  that  he  studied 
there  were  two  pouches,  the  orifices  being  to  the  right  and  left  of  the 
common  bile-duct. 

INFANTILE    STENOSIS   OF   THE    PYLORUS    (CONGENITAL 
HYPERTROPHIC    STENOSIS) 

This  is  a  condition  producing  symptoms  in  the  early  weeks  of 
life  characterized  by  propulsive  vomiting  associated  with  a  definite 
pyloric    tumour.     Among   its   many   names,    "  infantile "    stenosis   is 


Fig.  366. — Duodenal  pouches.     {Keith.) 

A,  Aii  early  stage;    b,  a  small  pouch  to  the  right  of  the  common  bile-duct; 
c,  pouches  on  each  side  of  the  duct. 

preferable,  as  its  causation  is  not  certain,  and  the  name  often  applied 
to  it — congenital  hypertrophic  stenosis — is  therefore  misleading. 

Although  tbe  first  case  of  this  disease  was  recorded  in  1788  by  Hezekiah 
Bardsley  (Osier)  as  "  scirrhus  of  the  pylorus,''  it  is  only  of  recent  years  that 
the  condition  has  been  readily  recognized,  largely  owing  to  the  work  of 
John  Thomson.  It  must  certainly  be  regarded  as  uncommon.  In  spite  of 
the  considerable  attention  directed  to  it  within  the  last  few  years,  up  to 
May,  1905,  Scudder  and  Quinby  had  collected  only  115  cases.  During  the 
years  1899-1908  only  6  cases  were  met  with  at  the  London  Hospital,  and 
no  case  was  operated  upon.  Coutts  had  met  with  only  1  case  during 
the  last  twelve  years  at  the  East  London  Children's  Hospital,  and  during 
this  time  the  condition  had  been  found  there  in  only  3  post-mortems. 

Etiology. — A  considerable  difference  of  opinion  exists  with 
regard  to  causation.  There  are  two  principal  theories — (1)  that  the 
condition  is  primary  and  due  to  congenital  overgrowth  of  muscle  ; 
(2)  that  it  is  secondary  to  pyloric  spasm.  Cautley  and  Dent  uphold 
the  former  theory ;  Robert  Hutchison  and  John  Thomson  the  latter, 
which  receives  the  greater  amount  of  support.  In  favour  of  its 
secondary  origin  is  the  fact  that  it  has  never  been  met  with  in  the 
foetus.     Keith  states  that  there  is  not  a  single  specimen  in  museums 


INFANTILE    PYLORIC   STENOSIS 

of  a  stenosis  of  pylorus  of  this  nature  obtained  from   young  or  new- 
born  infants. 

It  has  been  suggested,  as  explaining  differences  in  the  resull  of 
treatment  (p.  318),  bhat  there  are  two  groups  of  cases,  one   a    true 

congenital  condition,  the  other  the  result  of  pyloric  spasm. 

Infantile  stenosis  is  more  frequently  me1  with  in  male  than  in 
female  children  (80  per  cent,  males);  of  the  6  cases  at  the  London 
Hospital,   5  were  males. 

The  stomach  is  large  and  has  thickened  walls.  The  pyloric  region 
feels  firm,  and  on  section  shows  a  marked  thickening  due  to  hyper- 
plasia of  the-  circular  muscular  fibres,  sharply  limited  on  the  duo- 
denal side,  but  extending  for  some  distance  into  the  pyloric  antrum. 
(Fig.  367.)  The  pyloric  canal  may  be  completely  blocked  to  the 
passage  of  fluid,  although  a  probe  may  pass  readily.  The  mucous 
membrane  in  the  pyloric  region  is  thrown  into  longitudinal  folds 
(Fig.  368).  As  Cautley  and  Dent  have  pointed  out,  "A  single 
longitudinal  reduplication  of-  the  mucous  membrane,  much  more 
marked  than  any  other  fold,  forms  a  conspicuous  feature  in  many 
of  the  specimens.  This  prominent  fold  may  be  compared  to  the 
verumontanum  of  the  male  urethra.  Indeed,  these  stomachs  in 
appearance  commonly  resemble  the  dissected  -  out  bladder  and 
prostate." 

A  chronic  gastritis  often  complicates  these  cases,  and  aids  in  the 
production  of  the  obstruction. 

Symptoms. — These  are  characteristic.  The  child  is  perfectly 
healthy  at  birth,  and  in  most  cases  is  breast-fed  for  about  a  fortnight 
and  does  well.  Then  vomiting  unaccountably  commences,  perhaps 
as  early  as  three  days  or  as  late  as  six  weeks  after  birth.  It  is  forcible, 
projectile,  contains  mucus,  and  occurs  sometimes  after  every  feed, 
at  others  after  three  or  four  have  been  retained.  Bile  is  never  present 
in  the  vomit.  The  food  is  changed  ;  apparent  improvement  occurs 
in  many  cases  for  a  few  hours  or  a  day,  but  relapse  inevitably  occurs. 
Considerable  delay  in  the  adoption  of  proper  treatment  is  often 
occasioned  by  this  intermission.  The  child  loses  weight  and  becomes 
constipated. 

If  the  abdomen  is  examined  shortly  after  a  meal,  peristalsis  may 
be  noticed  passing  across  the  epigastric  region  from  left  to  right,  and 
a  definite  tumour  lying  transversely — the  hypertrophied  pyloric 
portion  of  the  stomach — may  be  felt.  The  remainder  of  the 
abdomen  is  sunken.     In  some  cases  tetany  develops. 

Diagnosis. — The  history  of  vomiting  coming  on  a  few  days  or 
weeks  after  birth,  its  projectile  character,  the  presence  of  visible 
peristalsis  and  a  palpable  tumour,  make  a  clinical  picture  which  is 
immistakable. 


Fig.  367. — Infantile  pyloric  stenosis. 

a.   External  appearance,  with  section  in  pyloric  region  showing  gTeat   increase   in   muscular  coat; 
B,  section  showing  increase  of  muscular  coat  in  the  pyloric  antrum. 

(London  Hospital  Museum  and  Pathological  Institute.) 

316 


INFANTILE    PYLORIC   STENOSIS 


Willcox  and  Miller  have  shown  that  the  condition  may  bediag 
bom  acid  dyspepsia  with  pyloric  Bpasm  by  examination  of  the  stomach 
contents.  In  infantile  stenosis  the  total  acidity  and  active  IM'I  are 
l,.w .  munis  is  present  in  considerable  amount,  and  Eerment  activitj 
is  high.  In  pyloric  spasm,  on  the  other  hand,  the  total  acidity  is 
high,  mucus  is  absent,  and  the  Eerment  activity  is  low.  They  also 
point  out  that  acid  dyspepsia  presents  neither  visible  peristalsis  noi 

tumour,  and   that    it    OCCUTS  in   infants  of  3  months  or  older. 

Prognosis.- --This  is  largely  determined   by  the  time  at     which 
(h,.  condition  is  recognized  and  treatment  adopted.     If  untreated  or 
treated    late,    it    is   in- 
evitably fatal. 

Of  the  <)  eases,  all 
under  the  age  of  6  months. 
treated  by  medical  means 
at  the  London  Hospital, 
all  died.  Neuratb  has  re- 
corded 41  cases  in  infants 
less  than  a  year  old.  all 
of  whom  died  under  medi- 
cal treatment.  Cautley 
and  Dent  state  that,  un- 
less operated  upon,  all 
die  before  reaching  the 
age  of  4  months.  Robert 
1 1  ui  ehison  records  a  death- 
rate  of  78  per  cent,  in  a 
series  of  64  cases  medi- 
cally treated  at  Great 
Ormond  Street  Children's 
Hospital.      Thomson  has 

had  41  cases  under  his  care  :  27  were  submitted  to  operation,  with  S  recoveries; 
in  13  not  operated  upon  there  were  4  recoveries.  Still  has  had  42  cases  with 
36  complete  histories  :  of  14  which  were  operated  upon,  8  recovered  ;  whilst 
of  the  22  who  were  medically  treated,  11  recovered.  On  the  other  hand. 
Robert  Hutchison  has  seen  20  cases  of  undoubted  infantile  stenosis  in 
his  private  practice :  of  these  17  were  treated  at  home,  and  all  recovered 
without  operation ;  3  were  sent  into  hospital,  and  2  died.  Bloch  has  re- 
ported 12  cases  :  8  patients  recovered  after  medical  treatment,  2  died  after 
operation,  and  2  were  moribund  when  first  seen.  Heubner  records  lit 
recoveries  out  of  21  cases  treated  medically. 

There  can  be  no  doubt  that  the  prognosis  is  grave,  and  that 
spontaneous  cure  rarely  if  ever  occurs  ;  if  the  condition  be  recognized 
and  treated  at  an  early  stage,  recovery  will  take  place  in  the  majority 
of  cases.  This  opinion  is  supported  by  Deaver  and  Ashurst,  who 
state  it  as  their  belief  that  "  in  the  immense  majority  of  cases,  medical 
treatment  promptly  instituted  and  energetically  applied  will  be 
successful  in  curing  the  patient." 


Fig.  368.  Infantile  pyloric  stenosis.  Stomach 
opened  to  show  the  longitudinal  folds 
of  mucous  membrane  in  pyloric  portion. 

(London  Hospital  Museum.) 


318  THE   STOMACH   AND    DUODENUM 

The  ultimate  condition  of  these  children  remains  for  further 
investigation.  Maylard,  Robson,  and  others  have  recorded  cases  of 
chronic  gastric  disease  in  young  adults  due  to  congenital  narrowness 
of  the  pylorus,  with  dilatation  of  the  stomach,  and  cases  have  come 
under  my  notice  in  which  symptoms  of  dilatation  of  the  stomach  in 
early  adult  life  were  associated  with  a  history  of  difficulty  in  feeding 
in  infancy.  The  relation  of  these  cases  to  the  disease  under  discussion 
has  yet  to  be  fully  worked  out. 

Treatment. — Opinions  differ  as  to  the  advisability  of  surgical 
treatment  at  any  stage  of  the  disease.  All,  however,  are  agreed  that 
lavage  and  appropriate  feeding  should  be  adopted  in  the  early  stages. 

Robert  Hutchison  considers  that  "  operation  is  never  in  any  sense 
justified  in  these  cases,"  and  Carpenter  states  that  medical  treatment 
has  proved  "  eminently  satisfactory."  On  the  other  hand,  Fisk  holds 
that  all  cases  should  be  submitted  to  surgical  treatment  after  a  week 
or  ten  days'  careful  feeding.  It  has  been  stated  by  Harold  Stiles 
that  the  cases  winch  get  well  are  cases  of  pyloric  spasm  without  con- 
genital hypertrophy,  and  that  the  treatment  of  the  true  stenosis  is 
surgical. 

In  one  patient  under  my  observation  in  whom  all  the  symptoms — 
propulsive  vomiting,  visible  peristalsis,  and  the  presence  of  a  tumour — 
were  those  of  congenital  stenosis,  recovery  followed  lavage  continued 
for  over  three  months,  and  now  at  the  age  of  5  the  boy  is  in  good 
health. 

The  stomach  should  be  washed  out  daily,  and  small  feeds  of 
peptonized  milk  given.  Gastric  lavage  is  easily  carried  out  through 
a  No.  12  rubber  catheter  attached  to  a  glass  funnel.  If  vomiting  is 
severe,  normal  saline  enemata  of  2  to  3  oz.  should  be  given  two  or 
three  times  a  day.  Lavage  with  suitable  feeding  must  be  continued 
often  for  three,  four,  or  five  months.  At  first  there  is  no  gain  in  weight 
and  the  child  may  appear  to  be  going  downhill.  Hutchison  states 
that  this  should  not  prevent  continuance  of  lavage. 

This  treatment  must  be  persisted  in  until  the  necessity  for  surgical 
intervention  arises  or  the  stomach  is  repeatedly  found  free  from  curds. 

If,  in  spite  of  lavage,  weight  is  steadily  lost  and  the  quantity  of 
curd  returned  shows  no  diminution,  operation  should  be  undertaken. 
Since  surgical  treatment  was  first  advocated  by  Schwyzer,  in  1896, 
various  operations  have  been  performed,  among  others  pyloroplasty, 
pylorodiosis  (pyloric  dilatation),  and  gastroenterostomy.  If  operation 
be  indicated,  some  form  of  pyloroplasty  is  undoubtedly  the  ideal 
procedure.  The  death-rate  of  all  methods  of  operative  treatment  is 
high — taken  as  a  whole,  certainly  not  less  than  40  per  cent. 

A  considerable  number  of  the  cases  of  pylorodiosis  have  relapsed. 

Nicoll's  operation,  which  has  hitherto  given  the  best  results  with 


GASTRIC    HERNIA  3*9 

the  lowest  death  rate,  is  performed  aa  follows:  A  V-shaped  incision 
is  made  in  the  pylorus  down  to  the  mucosa;  the  pylorus  is  then 
forcibly  Btretched  l>v  forceps  introduced  through  a  separate  incision 
in  the  stomach  wall,  and  the  pyloric  incision  sewn  up  in  a  Y-shaped 
manner.     \<>  relapse  has  followed  this  operation. 

Some  such  operation  as  this  should  be  performed  when  surgical 
intervention  becomes  necessary;  if  it  be  impossible,  then  gastro- 
jejunostomy should  be  done. 

HERNIA    OF    STOMACH 

The  stomach  in  rare  instances  has  been  found  in  both  congenital 
and  acquired  umbilical  hernias,  especially  the  former,  in  postoperative 
ventral  hernias,  and  more  rarely  still  as  a  content  of  the  sac  in  inguinal 
and  femoral  hernias.  It  is,  however,  most  often  found  in  hernia  of 
the  diaphragm  ;  thus,  in  59  cases  collected  by  Lawford  Knaggs,  the 
stomach  was  present  in  almost  all,  but  in  only  9  cases  was  it  the  sole 
content. 

In  most  cases  the  condition  is  present  at  birth,  and  observed  in 
infants  who  are  stillborn  or  who  do  not  survive  long.  In  others 
the  opening  is  congenital,  but  the  protrusion  of  the  stomach  occurs 
later ;  in  a  few  the  opening  is  the  result  of  accident.  A  part, 
usually  the  pyloric  portion,  or  the  whole  of  the  stomach  may  be 
involved. 

In  a  few  cases  in  which  adult  life  has  been  reached,  gastric  symptoms, 
such  as  discomfort  after  food,  flatulence,  or  even  pain,  are  present 
and,  if  the  patient  is  a  middle-aged  male,  may  lead  to  suspicion  of  a 
chronic  gastric  or  duodenal  ulcer ;  in  other  cases,  acute  dilatation 
or  volvulus  of  the  stomach  may  supervene.  It  may  be  complicated 
by  tetany,  as  in  a  case  recorded  by  Russell  Reynolds.  It  is  a  con- 
dition that  should  be  borne  in  mind  in  obscure  gastric  cases.  The 
position  of  the  heart  and  the  abnormal  area  of  resonance  will  point 
to  the  correct  diagnosis,  which  will  be  confirmed  by  X-ray  examination 
after  a  bismuth  meal. 

GASTROPTOSIS 

In  this  condition  the  stomach  is  displaced  downwards,  alone,  or 
more  usually  in  association  with  the  right  kidney,  or  all  the  abdominal 
viscera.  It  is  commonly  met  with  in  women,  and  may  cause  symptoms 
owing  to  its  interference  with  the  motor  power  of  the  stomach. 

Etiology. — The  principal  factor  in  the  production  of  gastroptosis 
is  loss  of  tone  in  the  abdominal  muscles,  which  may  be  due  to  many 
causes.  In  the  few  cases  in  which  the  stomach  alone  is  prolapsed 
the  condition  may  be  congenital,  or  perhaps  is  sometimes  secondary 
to  atonic  dilatation  of  the  stomach. 


32o  THE   STOMACH   AND   DUODENUM 

The  stomach,  is  usually  somewhat  dilated.  It  may  assume  an 
almost  horseshoe  shape,  allowing  the  pancreas  to  appear  above  the 
lesser  curvature,  or  in  rare  cases  the  pylorus  itself  may  descend  and 
the  stomach  become  vertical. 

Symptoms  are  absent  in  many  cases,  and  when  present  resemble 
those  of  atonic  dilatation  of  the  stomach.  It  should  be  remembered 
that  they  do  not  depend  upon  the  abnormally  low  position  of  the 
stomach,  but  upon  motor  insufficiency  from  general  ill-health  or 
from  pyloric  obstruction. 

The  patients  are  usually  thin,  and  often  the  subjects  of  neurasthenia. 
The  chief  complaint  is  usually  of  a  feeling  of  fullness  after  meals,  often 
necessitating  loosening  of  the  clothes.  Vomiting  is  unusual,  but 
nausea  and  retching  are  common.  In  many  cases  pain  is  complained 
of  directly  food  enters  the  stomach. 

Diagnosis. — Examination  of  the  patient  readily  leads  to  correct 
diagnosis.  Inspection  of  the  abdomen  when  the  patient  is  standing 
will  usuallv  reveal  the  prominent  lower  belly  characteristic  of  entero- 
ptosis.  If  the  stomach  has  descended,  the  low  position  of  the  lesser 
curvature  is  readily  seen,  often  immediately  above  the  umbilicus, 
moving  up  and  down  with  respiration. 

Treatment. — Surgical  treatment  is  only  called  for  in  the  rare 
cases  in  which  obstruction  due  to  kinking  is  present  at  the  pylorus, 
and  is  not  remedied  by  medical  means,  such  as  rest  in  bed  with  the 
foot  of  the  bed  raised,  combined  with  abdominal  massage  and,  if  there 
is  evidence  of  retention  of  food,  gastric  lavage  for  at  least  three  weeks. 
On  the  resumption  of  the  erect  position  a  well-fitting  abdominal  belt 
should  be  worn. 

Manv  operative  procedures  have  been  advised  and  adopted  since 
Duret  sutured  the  anterior  gastric  wall  to  the  peritoneum  in  1894. 
Of  operations  designed  to  remedy  the  position  of  the  stomach  the 
best  is  undoubtedly  Sir  Frederic  Eve's  modification  of  Beyea's 
operation.  The  stomach  is  raised  to  the  under  surface  of  the  liver 
by  sutures  passed  through  the  attachment  of  the  lesser  omentum  to 
these  organs.  Beyea  reports  26  operations  ;  all  the  patients  except  3 
are  quite  well.  In  my  opinion,  however,  operations  of  this  nature 
are  not  more  successful  than  non-operative  treatment,  and  in  cases 
with  marked  obstruction  have  failed  to  relieve  the  symptoms  entirely. 
Other  surgeons,  among  whom  are  Deaver  and  Mayo  Robson, 
prefer  gastrojejunostomy  for  the  rare  cases  which  need  operation. 
But  it  is  in  atonic  stomachs  such  as  these  that  the  operation  is  liable 
to  be  followed  by  regurgitant  vomiting.  For  the  emphatically  rare 
cases  in  which  operative  measures  are  indicated,  I  believe  Finney's 
gastro-duodenostomy  gives  the  best  results,  and  I  have  used  it  with 
perfect  success. 


HOUR-GLASS    STOMACH 

GASTRIC   VOLVULUS 

In  gastric  volvulus  the  stomach  may  become  twisted  in  one  of 
three  directions:  (1)  Around  its  transverse  axis;  (2)  around  an 
antero-posterior  axis;  (3)  around  an  axis  al  right  angles  to  its 
greater  curvature. 

This  is  an  extremely  rare  condition,  of  which  the  recorded  cases  number 
20.  Deaver  and  Asluirsi  have  collected  13,  and  individual  cases  have  been 
recorded  by  Jiano,  Knaggs,  Hermes,  Tiirmoos,  Payer,  Niosi,  and  Delangre. 

Until  the  normal  relations  of  the  stomach  have  been  altered  in 
some  way,  volvulus  is  impossible.  It  may  arise  in  gastroptosis,  and 
has  occurred  (Knaggs)  in  association  with  diaphragmatic  hernia  ; 
in  3  cases  it  complicated  hour-glass  contraction  of  the  stomach 
in  which  the  pyloric  pouch  was  large ;  cases  have  been  recorded 
following  injury,  in  others  the  symptoms  have  appeared  suddenly 
during  apparent  health.  In  most  of  the  cases  the  stomach  became 
twisted  around  its  transverse  axis,  the  transverse  colon  passing  up- 
wards and  backwards.  As  a  result  of  this,  both  orifices  of  the  stomach 
are  usually  obstructed. 

Symptoms. — The  onset  is  sudden,  with  pain  in  the  epigastric 
region,  followed  by  collapse.  As  a  rule  the  patient  does  not  vomit, 
but  only  regurgitates  food  which  enters  the  oesophagus.  A  tense, 
resonant  swelling  rapidly  forms  in  the  epigastric  region.  The  signs 
resemble  in  many  respects  those  of  acute  dilatation  of  the  stomach, 
but  diagnosis  can  be  made  by  the  absence  of  vomiting  and  by  the 
impossibility  of  passing  a  tube  from  the  oesophagus  into  the  stomach. 

Treatment. — Operation  should  be  undertaken  at  once.  In 
most  cases,  as  soon  as  the  abdomen  is  opened  the  stomach  presents 
as  a  tense  cyst  which  usually  needs  puncture  before  the  type  to  which 
the  volvulus  belongs  can  be  determined  or  the  volvulus  reduced. 
The  opening  should  be  sutured  and  the  volvulus  reduced.  In  the 
usual  type  of  case  (1)  the  posterior  gastric  wall  presents. 

The  operations  recorded  number  14,  with  3  recoveries. 

HOUR-GLASS  STOMACH   (SEGMENTED   STOMACH— Wolfer) 

In  this  condition  the  stomach  is  divided  into  cavities,  as  a  rule 
two,  but  occasionally  three  or  even  four.  It  is  more  often  met  with 
in  women  than  in  men  ;  among  154  cases  collected  by  Schomerus, 
128  were  in  women. 

Etiology. — Its  chief  cause  is  gastric  ulcer  (Fig.  369) ;  more  rarely 
it  results  from  cancer  (Fig.  370) ;  very  rarely  indeed  it  may  be  con- 
genital. A  "  saddle-shaped  "  ulcer  of  the  lesser  curvature  usually 
produces  the  condition,  but  perigastric  adhesions  as  the  result  of 
the  ulcer  may  constrict   the   stomach  or    bind  it  to  the  abdominal 


322 


THE  STOMACH  AND  DUODENUM 


wall  or  liver  so  that  diverticula  are  formed.  Out  of  45  cases  oper- 
ated upon  and  reported  by  Mayo  Robson  and  Moynihan,  37  were 
the  result  of  ulcer  or  perigastritis.  Hour-glass  stomach  is  met  with 
as  a  complication  of  gastric  ulcer  in  from  3-3  per  cent.  (W.  J.  Mayo, 
in  925  operations)  to  9  per  cent.  (.Moynihan,  in  198  operations)  of  the 
cases.  I  believe  that  Mayo's  figures  represent  the  truer  proportion. 
Perigastric  adhesions  other  than  those  due  to  ulcer  may  cause 
the  condition.     It  may  be  the  result  of  the  healing  of  ulcers  after 


Fig.  369. — Hour-glass  stomach,  due  to  cicatrization  of  a  saddle- 
shaped  lesser-curvature  ulcer. 

(London  Hospital  Pathological  institute. ) 

corrosive  poisoning ;  I  have  recently  operated  upon  such  a  case. 
Cases  have  also  been  described  as  due  to  syphilis  of  the  stomach. 

Undoubtedly,  though  extremely  rarely,  the  condition  may  arise 
congenitally,  for  Delamere  and  Dieulafe,  and  Gardiner,  have  recorded 
cases,  and  according  to  Martin  there  is  a  specimen  in  the  McGill 
Museum.  As  the  stomach  in  the  early  stage  of  development  consists 
of  a  tubular  pyloric  portion  and  a  cardiac  pouch,  a  continuance  of 
the  foetal  condition  would  account  for  these  cases.     (Fig.  362.) 

The  constriction  is  generally  single  and  situated  towards  the 
pyloric  end  of  the  stomach,  and,  as  a  rule,  the  greater  curvature  is 
drawn  up  towards  the  lesser.  The  cardiac  pouch  is  usually  larger 
than  the  pyloric.  When,  however,  as  not  infrequently  happens, 
pyloric  obstruction  coexists,  the  pyloric  pouch  may  be  as  large  as 
the  cardiac.  The  recognition  of  this  fact  is  important,  for  the 
pyloric  pouch  may  be  mistaken  at  operation  for  the  whole  stomach, 
and  a  gastrojejunostomy  performed  on  it  with  a  fatal  result ;    well- 


I  U  H  K-Cil.ASS    STOMACH 


323 


known  Burgeons,  among  whom  are  Bier,  Czerny,  and  Bartmann,  have 
fallen  into  this  error,  and  recorded  their  experience  for  the  sake  of 
others.     It  may  also  become  the  scat  of  a  volvulus. 

Symptoms.  -These  resemble  very  closely  1  hose  of  pyloric  stenosis 
and  follow  in  many  cases  on  the  history  of  a  gastric  ulcer.  The 
physical  signs  may  render  a  diagnosis  possible  before  operation. 
These  depend  upon— (1)  inflating  the  stomach;  (2)  the  introduction 
of  fluid;  (■">)  examination  by  X-rays  after  a  bismuth  meal. 


Fig.  370. — Hour-glass  stomach  from  malignant  growth. 
A  portion  of  the  cardiac  pouch  has  been  removed. 

(Lou  ■ 

1.  Ou  inflating  with  C02  or  air,  the  upper  pouch  may  be  seen 
to  become  dilated,  aud  this  is  followed,  if  the  abdomen  be  watched 
for  a  few  minutes,  by  the  pyloric  pouch. 

2.  If  a  measured  quantity  of  liquid  has  been  passed  into  the 
stomach  through  a  tube,  a  large  portion  of  it  cannot  be  recovered. 
Moreover,  during  lavage,  after  the  fluid  has  returned  clear  there  may 
be  a  gush  of  cloudy  fluid  with  gastric  contents. 

It  may  be  impossible  to  obtain  any  fluid  even  when  splashing 
occurs,  the  fluid  having  passed  into  the  pyloric  pouch  (sign  of  para- 
doxical dilatation). 

On  passing  in  a  quantity  of  fluid  the  cardiac  pouch  may  become 
distended  first ;  this  gradually  subsides,  to  be  followed  by  another 
swelling  due  to  fluid  in  the  pyloric  pouch. 

3.  X-ray  examination  after  a  bismuth  meal  should  be  carried 
out  in  all  suspected  cases,  and  is  the  onlv  reliable  means  of  diagnosis 
(Fig.  364). 


324  THE   STOMACH   AND   DUODENUM 

In  rare  cases  the  constriction  is  close  to  the  cardia,  and  the  symptoms 
resemble  those  of  oesophageal  obstruction. 

Free  HC1  is  usually  absent  and  the  total  acidity  of  the  gastric 
contents  low. 

It  is  important  to  consider  every  case  of  dilated  stomach  as  a 
possible  hour-glass  stomach,  so  as  to  avoid  the  fatal  error  of  performing 
gastrojejunostomy  on  a  dilated  pyloric  pouch.  In  every  stomach- 
operation,  the  whole  of  the  stomach  must  be  examined  to  prevent 
such  errors  in  treatment. 

Treatment. — This  consists  in  providing  free  exit  for  the  stomach 
contents.  Gastrojejunostomy  should  be  done  in  every  case.  Where 
there  is  a  large  cardiac  pouch  with  a  small  pyloric  one,  this  operation 
will  suffice,  but  if  pyloric  stenosis  is  also  present  it  is  not  enough  ; 
gastroplasty  should  be  combined  with  it,  or,  as  suggested  by  von 
Hacker  in  1895,  and  by  Weir  and  Foote  in  1896,  a  separate  gastro- 
jejunostomy done  on  each  pouch.  This,  I  believe,  will  be  more  fre- 
quently done  in  the  future.  To  avoid  the  risk  of  hernia  between  the 
stomach  at  the  constriction  and  the  jejunum  between  the  two  openings, 
the  gut  should  be  united  to  the  stomach. 

Where  more  than  two  pouches  exist  they  should  be  connected 
by  gastro-gastrostomy,  and  then  gastrojejunostomy  performed  on 
the  largest  pouch. 

Other  operations  have  been  proposed,  such  as  gastroplasty  or  a 
gastro-gastrostomy  alone  :  but  Paterson  has  shown  that  these  are 
associated  with  25  to  30  per  cent,  of  relapses. 

If  the  condition  be  due  to  malignant  disease,  partial  gastrectomy 
should  be  performed. 

Results. — Veyrassat  has  collected  all  the  cases  recorded  to 
August,  1908.  There  are  181.  Of  these,  73  were  treated  by  gastro- 
jejunostomy ;  72  per  cent,  were  cured,  and  only  2-7  per  cent,  failed. 
Of  the  14  deaths,  6  were  due  to  the  anastomosis  being  done  to  the 
pyloric  pouch. 

ACUTE   DILATATION   OF    THE    STOMACH 

This  condition  is  by  no  means  uncommon.  Its  diagnosis  is  of 
the  utmost  importance  to  the  surgeon,  following  as  it  sometimes  does 
abdominal  operations,  with  an  inevitably  fatal  result  unless  recognized 
early.  There  is  no  doubt  that  many  cases  recorded  as  "  postoperative 
ileus  "  were  of  this  nature. 

Although  its  recognition  dates  from  the  description  given  in  the 
Guy's  Hospital  Reports  of  1872-3  by  Hilton  Fagge,  Rokitansky  in 
1842  had  drawn  attention  to  one  of  the  features  connected  with  it 
— compression  of  the  third  part  of  the  duodenum  by  the  mesentery 
and  superior  mesenteric  artery  as  a   cause  of  intestinal  obstruction 


ACUTK    DILATATION  325 

due    to    external    pressure.      Albrechl    in    1899   w&s   able   to 
19  cases  only;  by  1902,  Campbell  Thomson  published  the  records  of 
II     is<  -.  including  5  in  which  he  had  made  the  post-mortem  examina- 
tion.    Since    then    many  more   cases   have   1 n   published,  Xi<  liolls 

in  1908  analysing  225  collected  cases. 

Etiology. — The  condition  may  arise  after  operations  performed 
on  any  part  of  the  body,  but  most  often  follows  those  upon  the 
abdomen.  It  may  complicate  other  diseases,  appear  after  injury, 
or  in  rare  cases  arise  primarily  as  the  result  of  indiscretion  in  diet. 

It  may  be  met  with  at  any  age.  the  youngest  recorded  being  9  months, 
the  oldest  7")  years,  bul  it  is  most  common  in  youth  and  early  adult  life. 

Of  the  225  cases  collected  by  Nicholls,  -47  per  cent,  followed  operation, 
and  of  these  69  per  cent,  were  abdominal,  most  often  on  the  biliary  tract, 
next  in  frequency  on  the  kidney,  then  on  the  appendix.  Dilatation  may 
follow  injury  (in  17  out  of  217  cases  collected  by  Laffer,  the  injury  in  5  being 
abdominal).  In  40  cases  it  complicated  some  other  disease — most  often 
pneumonia  or  typhoid.     In  11  cases  spinal  curvature  was  present. 

Many  opinions  have  been  advanced  as  to  it-  cause  :  (1)  Obstruc- 
tion of  the  duodenum  by  the  superior  mesenteric  artery  (Rokitan- 
sky,  Albrecht) ;  (2)  excessive  secretion  (Fagge,  Henry  Morris) ;  (3) 
paralysis  (Campbell  Thomson) ;  (-4)  compression  of  the  third  portion 
of  the  duodenum  by  the  paralysed  dilated  stomach  (Box  and 
"Wallace) ;  (5)  septic  intoxication. 

The  condition  probably  consists  primarily  of  a  paralytic  dilatation 
of  the  stomach.  This  is  the  conclusion  arrived  at  by  most  modern 
writers  on  the  subject.  It  may  in  a  certain  number  of  cases  be  kept 
up  or  complicated  by  mesenteric  compression,  but  out  of  120  cases 
in  LafTer's  series,  in  only  27  was  it  of  this  type. 

It  is  stated  by  Stavely  that  a  chronic  dilatation  of  the  duodenum  or 
stomach  may  result  from  pressure  of  the  mesenteric  vessels.  In  one 
case  retrocolic  gastro-duodenostomy  was  performed  for  this  condition. 

Morbid  anatomy. — The  post-mortem  appearances  in  all  the 
recorded  cases  are  similar.  The  stomach  is  dilated  into  a  huge 
V-shaped  tube  which  may  fill  the  whole  abdomen.  There  is  usually 
a  sharp  kink  at  the  lesser  curvature.  The  dilatation  rarely  affects 
the  stomach  alone,  but  may,  as  previously  stated,  stop  short  at  the 
point  at  which  the  superior  mesenteric  vessels  cross  the  duodenum, 
and  in  one  instance  (Baumler)  there  was  a  localized  constriction  here 
with  a  well-marked  circular  area  of  necrosis  in  the  intima  of  the  gut. 
But  in  some  cases  the  dilatation  extends  lower  and  involves  the 
jejunum  to  a  greater  or  less  degree. 

The  walls  of  the  stomach  are  thin,  and  the  mucous  membrane 
shows  haemorrhages.  As  noted  by  Fagge,  whitish  striae  are  frequently 
observed  on  its  peritoneal  surface,  the  result  of  distension. 


326  THE   STOMACH   AND   DUODENUM 

If  an  abdominal  operation  has  been  performed,  there  is  usually 
no  trace  of  peritonitis. 

Symptoms. — The  onset  is,  as  a  rule,  sudden,  in  the  postoperative 
cases  occurring  from  twelve  to  forty-eight  hours  after  the  operation, 
usually  about  twenty-four  ;  it  has  been  delayed  to  the  second  week. 
Epigastric  pain  and  a  feeling  of  distension  are  first  complained  of,  and 
are  followed  by  the  vomiting  of  large  quantities  of  fluid  with  very 
little  effort  but  with  no  relief.  The  fluid  is  usually  greenish-grey, 
turbid,  and  seldom  offensive.  As  the  disease  advances,  thirst  becomes 
intolerable,  the  pulse  rapid,  respiration  embarrassed,  and  there  is 
great  restlessness.     Tetany  has  been  observed. 

On  examination,  the  great  abdominal  tympanitic  distension  is 
evident,  chiefly  on  the  left  and  in  the  middle  line.  Splashing  is  readily 
obtained,  and  peristalsis  very  rarely  seen.  If  the  stomach-tube  is 
passed  there  is  an  abundant  escape  of  gas  and  a  large  quantity  of 
fluid  is  evacuated,  but  the  stomach  refills  after  a  short  time. 

Diagnosis. — Early  recognition  is  important,  particularly  in  the 
postoperative  cases  where  complications  due  to  the  anaesthetic  or  to 
the  operation  may  be  more  in  the  mind  of  the  surgeon.  It  may  be 
confused  with  postansesthetic  vomiting,  but  this  does  not  persist ;  or 
it  may  appear  for  the  first  time  twenty-four  hours  after  operation. 
In  the  recorded  cases  the  postaneesthetic  vomiting  had  ceased. 
Early  peritonitis  following  abdominal  operations  may  be  suspected, 
but  the  symptoms  of  the  two  conditions  differ  entirely.  The  tem- 
porary relief  following  the  evacuation  of  gas  and  fluid  by  a  stomach- 
tube  should  lead  to  the  correct  diagnosis. 

Prognosis. — The  death-rate  of  recorded  cases  is  63  per  cent., 
most  of  the  deaths  occurring  within  the  first  week. 

Treatment. — As  soon  as  it  is  even  suspected  that  this  con- 
dition is  supervening,  the  stomach-tube  should  be  passed  and  lavage 
employed.  The  recumbent  position  with  the  foot  of  the  bed  raised 
should  be  adopted.  It  has  been  recommended  that  in  persistent 
cases  the  patient  should  lie  on  the  face  or  assume  the  knee-elbow 
position. 

If  these  measures  fail,  what  is  to  be  done  ?  Operation  has  been 
carried  out  in  14  cases  with  2  recoveries,  and  in  1  of  these  (Mac- 
evitt)  after  the  abdomen  was  opened — the  diagnosis  not  having  been 
made  before  operation — the  operator  contented  himself  with  passing 
a  stomach-tube.  In  the  second,  a  kink  at  the  duodeno-jejunal  flexure 
was  relieved  by  suturing  the  jejunum  to  the  transverse  meso-colon 
(Petit).  Gastrotomy  has  failed  to  relieve  in  5  instances.  Gastro- 
jejunostomy has  been  recommended  as  applicable,  but  should  never, 
in  my  opinion,  be  done.  In  the  2  recorded  cases  (Kehr,  Korte),  death 
ensued.       The  condition    has    arisen    after    and    in    spite   of   gastro- 


CHRONIC    DILATATION  327 

jejunostomy,  and,  if    uol    relieved    by   lavage   and    position,    is   un- 
likely to  !>'■  cured  by  this  operation. 

1  am  of  opinion  thai  operation  is  uol  Indicated.  In  the  early 
oases,  life  will  1"'  saved  by  lavage;  in  those  thai  are  overlooked,  uo 
Burgical  treatmenl  \\ ill  be  of  any  avail. 

CHRONIC    DILATATION    OF    THE    STOMACH 
These  cases  fall  into  two  groups  : — 

1.  Those    in  which  the  dilatation  is  the  resull  of  mechanical 

obstruction  in  the  region  of  the  pylorus — obstructive. 

2.  Those  in   which   the  enlargement  of  the    stomach   is  the 

resull  of  weakness  of  its  walls — atonic  dilatation. 

The  former  variety  possesses  most  interest ;  it  is  doubtful  if  the 
Becond  form  should  ever  be  treated  surgically. 

It  must  always  be  remembered  that  gastric  dilatation  is  not  a 
disease,  but  a  symptom. 

1.  Obstructive  Dilatation 

These  cases,  again,  fall  into  two  groups,  each  of  which  is  further 
subdivided  into  those  clue  to  malignant  growth  and  those  the  result 
of  simple  causes.     The  groups  are — 

(1)  Those  in  which  the  cause  is  in  the  wall  of  the  stomach  or 

duodenum. 

(2)  Those  in  which  it  is  external  to  them. 

i.  (a)  Malignant  disease  of  the  stomach  or  duodenum. 

(b)  Ulcers  of  the  stomach  or  duodenum  and  their  sequela?. 
Simple     tumours ;     infantile    hypertrophic    stenosis ; 
fibrous  stricture  ;    gastroptosis. 
ii.  (a)  Malignant    disease   of    the    pancreas,    gall-bladder,  and 
biliary  passages. 
(b)  Non-malignant    disease  of   gall-bladder  and  bile-ducts. 
Perigastritis  ;    mobile  kidney  ;    aneurysm. 
Carcinoma  of  the  stomach  frequently  arises  in  the  pyloric  region, 
and  is  one  of   the  common    causes  of   obstructive  dilatation  of   the 
stomach  (p.  380).     The  onset  of  symptoms  of  interference  with  gastric 
motility  in  a  previously  healthy  adult  shoidd  always  direct  attention 
to  this  possibility. 

Gastric  dilatation  may  be  due  to  the  presence  of  a  chronic  ulcer 
of  the  pyloric  region  of  the  stomach,  to  the  contraction  of  scar  tissue 
formed  as  the  result  of  its  healing,  to  perigastric  adhesions,  or  to  ulcer 
of  the  first  part  of  the  duodenum.  The  last-named  is  the  most 
common  simple  cause.  The  obstruction  is  sometimes  due  to  spasm  of 
the  pylorus  brought  about  by  the  irritation  of  the  ulcer,  but  in  such 
cases  the  dilatation    is    rarely  great,   and   seldom   in  itself   calls  for 


328  THE   STOMACH   AND   DUODENUM 

surgical  assistance,  though  it  may  be  advisable  to  deal  with  the 
ulcer  by  surgical  means. 

Dilatation  may  be  due  to  a  simple  polypus  playing  the  part  of 
a  ball  valve  (p.  377). 

Infantile  stenosis  of  pylorus  is  considered  on  p.  314.  In  some 
cases,  recovery  from  this  condition  is  followed  by  definite  symptoms 
of  secondary  dilatation  of  the  stomach  later.  Maylard  has  called 
attention  to  a  group  of  cases  of  simple  narrowing  of  the  pylorus 
which  may  be  congenital. 

Simple  fibrous  stricture  of  the  pylorus  is  occasionally  the  cause 
of  obstructive  dilatation.  Mansell-Moullin  has  called  attention  to 
this  fact,  and  describes  the  condition  found  at  operation  as  follows  : 
"  It  simply  seemed  as  if  the  circular  muscular  fibres  had  disappeared 
and  had  been  replaced  by  tough  or  unyielding  fibrous  tissue."  He 
goes  on  to  say  :  "  The  most  probable  explanation  is  that  the  fibrous 
degeneration  is  the  outcome  of  long-continued  spasmodic  contraction 
caused  by  persistent  dyspepsia." 

I  have  operated  upon  three  such  cases  in  which  at  operation 
neither  adhesion  nor  trace  of  scarring  was  present. 

Gastroptosis  may  cause  obstructive  dilatation  by  producing  a  kink 
at  the  pylorus  (p.  320). 

Malignant  growths  of  the  pancreas,  gall-bladder,  or  bile-ducts 
may  produce,  among  other  symptoms,  those  of  dilatation  of  the 
stomach. 

Perigastric  adhesions,  which  are  due  most  often  to  chronic  gastric 
ulcer  or,  less  frequently,  to  gall-stones  and  their  sequelae,  a  distended 
gall-bladder,  or  the  obstruction  caused  by  the  ulceration  of  a  gall- 
stone into  the  duodenum  or  stomach,  may  cause  symptoms  of  gastric 
dilatation. 

Mobile  kidney,  by  its  traction  on  the  duodenum,  is  an  unusual  but 
very  definite  cause. 

Dilatation  due  to  pressure  of  a  simple  tumour  external  to  the 
stomach  is  an  extremely  rare  occurrence.  It  has  been  recorded  as 
the  result  of    pressure  by  an  aneurysm. 

2.  Atonic  Dilatation 

This  is  a  condition  in  which,  owing  to  weakness  of  the  stomach- 
walls,  the  gastric  contents  are  not  passed  rapidly  enough  into  the 
duodenum.  Amenable  to  medical  treatment  in  its  early  stages,  it  is 
but  rarely  that  it  becomes  so  extreme  that  surgery  has  to  be  called 
in  to  its  aid. 

Symptoms. — In  the  early  stages  the  symptoms  are  indefinite 
and  consist  of  sastric  discomfort  or  a  sense  of  fullness  after  meals. 


CHRONIC    DILATATION  329 

h  ,it  tin-  stage  gastric  motility  were  estimated  by  any  of  the  methods 
mentioned  on  p.  309,  it  would  be  Eound  deficient. 

In  many  of  the  simple  oases  theie  is  a  previous  history  of 
duodenal  or  gastric  ulcer,  or  of  dyspepsia. 

Later  the  symptoms  become  characteristic  :  I I   is  retained  in  the 

stomach  and  vomited  at  irregular  intervals  of  two  or  three  days — 
the  vomit  consists  of  large  quantities  of  sour-smelling  fluid,  containing 
perhaps  fragments  of  food  taken  several  days  before ;  there  are 
associated  thirst,  wasting,  and  constipation,  and  the  patient  pres* 
the  dry,  harsh  skin  seen  when  the  tissues  are  deprived  of  water. 
At  this  stage,  too,  free  HC1  is  usually  absent  and  the  total  acidity 
low,  whether  the  dilatation  be  due  to  simple  or  malignant  causes. 

Tetany  may  complicate  gastric  dilatation  from  any  cause,  but  as 
a  rule  it  is  only  seen  in  simple  cases.  Attention  has  been  particularly 
directed  to  this  by  Mayo  Robson,  who  in  1898  pointed  out  the 
necessity  for  surgical  treatment  of  the  gastric  dilatation  when  this 
complication  has  supervened.  Its  recognition  is  important  as,  pro- 
bably of  toxic  origin,  it  is  a  serious  complication  and  fatal  in  a  large 
proportion  of  cases  unless  treated  by  operation.  In  its  fully  developed 
form  it  is  uncommon  (McKendrick  in  1907  was  able  to  collect  63 
cases),  but  lesser  degrees  are  far  from  rare.  Patients  complain  not 
infrequently  of  formication  or  numbness,  or  of  heaviness  in  the  limbs, 
followed  by  cramps. 

Examination. — The  enlarged  stomach  may  be  distinctly  seen, 
reaching  in  some  cases  as  low  as  the  pubes,  and  peristalsis  may 
be  noticed  crossing  from  left  to  right,  or  it  may  be  elicited  by 
gently  flicking  the  abdomen.  The  area  of  stomach-resonance  is 
increased,  and  splashing  sounds  may  be  obtained  over  an  area  not 
usually  occupied  by  the  stomach  at  a  time  when  it  should  be  empty. 
When  any  doubt  exists  as  to  the  presence  of  dilatation,  the  stomach 
should  be  distended  with  air  or  gas.  The  abdomen  should  be  care- 
fully examined  for  evidences  of  tumour,  mobile  kidney,  or  gastroptosis, 
*nd  the  possibility  of  hour-glass  contraction  considered. 

Diagnosis. — There  are  two  essential  points  to  consider  in  the 
diagnosis  of  gastric  dilatation — (1)  the  dirvcovery  of  the  dilatation  ; 
(2)  the  discovery  of  its  causation. 

(1)  Diagnosis  has  to  be  made  from — 

(a)  Gastroptosis.— In  these  patients,  usually  women,  the  history 
is  one  of  vague  indigestion  and  could  only  be  mistaken  for  that  of 
a  very  early  stage  of  gastric  dilatation.  It  is  more  often  confused 
with  the  early  symptoms  of  carcinoma.  Distension  of  the  stomach 
will  show  the  gastroptosis,  and  passage  of  the  stomach-tube  will 
demonstrate  any  motor  insufficiency  ;  if  this  is  present  it  may  require 
surgical  treatment. 


330  THE    STOMACH    AND    DUODENUM 

(b)  Hour-glass  stomach.- — It  is  rarely  possible  to  distinguish  this 
by  its  symptoms  from  pyloric  obstruction,  which  not  infrequently 
coexists;  but  its  possible  presence  should  always  be  borne  in  mind, 
and  its  diagnosis  attempted,  in  order  to  prevent  errors  in  operative 
treatment.  Certain  symptoms  (p.  323)  noticed  on  the  passage  of  a 
stomach-tube  may  facilitate  the  diagnosis:  in  other  cases,  X-ray 
examination  after  the  ingestion  of  bismuth  will  reveal  the  condition. 

(2)  An  attempt  must  be  made  to  discover  the  nature  of  the  dilata- 
tion or  its  causation.  Chief  reliance  has  to  be  placed  on  a  careful 
anamnesis.  A  history  of  preceding  abdominal  disease,  pointing  to 
gastric  or  duodenal  ulcer,  is  obtained  in  many  of  the  simple  cases. 
The  rapid  onset  of  the  symptoms  of  dilatation  in  an  adult  who  has 
had  no  previous  gastric  trouble  will  point  very  strongly  to  malignant 
disease. 

Examination  of  the  stomach  contents  after  a  test  meal  may  be  of 
service  in  the  differential  diagnosis. 

A  history  of  biliary  trouble  would  point  to  the  condition  being 
secondary  to  disease  of  the  biliary  passages  ;  one  of  difficult  feeding 
in  infancy  or  of  lifelong  dyspepsia  followed  by  dilatation  of  the 
stomach  would  suggest  a  congenital  origin. 

Prognosis. — Obstructive  dilatation  is  a  disease  of  grave  prognosis 
unless  treated  surgically  ;  but  if  treated  on  modern  surgical  lines 
the  death-rate  is  small  and  the  ultimate  recovery  in  the  majority  of 
cases  perfect.  In  cases  in  which  tetany  has  developed  the  death- 
rate  under  medical  treatment  has  been  from  70  to  90  per  cent.  Under 
surgical  treatment  the  prognosis  even  of  the  cases  with  tetany  has 
been  greatly  improved  ;  thus,  McKendrick  has  collected  24  such  cases 
with  only  3  deaths. 

Treatment  of  chronic  dilatation. — Obstructive  dilatation 
of  the  stomach  should  be  surgically  treated  ;  it  is  useless  attempting 
to  cure  the  condition  by  lavage. 

The  exact  operation  necessary  will  depend  on  its  causation.  The 
choice  lies  in  the  majority  of  cases  between  gastrojejunostomy  and 
gastro-duodenostomy  (Finney's  method).  Operations  such  as  pyloro- 
diosis  or  pyloroplasty  are  followed  by  relapse  in  many  cases,  and 
should  not  be  considered. 

In  cases  in  which  the  dilatation  is  due  to  mobility  of  the  right  kid- 
ney, this  organ  should  be  fixed  before  resorting  to  further  treatment. 
In  cases  due  to  disease  of  the  gall-bladder,  the  removal  of  gall-stones 
and  division  of  adhesions  may  suffice  to  cure. 

If  the  obstruction  is  due  to  congenital  narrowing  of  the  pylorus 
or  to  the  "  fibrous  r'  variety  of  stricture,  gastro-duodenostomy  by 
Finney's  method  is  the  best  operation,  restoring  the  condition  of  the 
parts  as  nearly  as  possible  to  normal.     When,  owing  to  the  presence 


RUPTURE    OF    STOMACH 

hive  ulceration  or  of  many  adhesions  around  the  pylorus,  this 
is  inadmissible,  posterior  uo-loop  gastrojejunostomy  should  be  per- 
formed, the  anastomosis  being  made  to  the  pyloric  portion  of  the 
stomach. 

The  resull  of  surgical  treatmenl  on  these  lines  ia  most  gratifying  ; 
the  death-rate  in  large  numbers  of  cases  does  nol  exceed  5  per  cent., 
ami  in  the  hands  of  those  who  are  doing  much  work  of  this  kind  is 
Less  I  ban  2  per  rent. 

Advanced  cases  of  atonic  dilatation  may  in  rare  instances  need 
surgical  treatment,  but  this  must  only  be  carried  out  after  the  failure 
of  prolonged  medical  treatment,  resl  in  bed,  and  lavage.  As  first 
pointed  <>ut  by  Mikulicz,  and  again  by  Paul  and  the  present  writer, 
gastrojejunostomy  in  this  condition  is  frequently  followed  by  the 
establishment  of  a  vicious  circle. 

In  these  cases  a  mechanical  factor  is  added,  namely,  kinking  of 
the  pylorus.  Finney's  operation,  followed  by  medical  treatment, 
will  give  relief,  and  should  be  carried  out. 

Attempts  have  been  made  to  treat  the  condition  by  folding  the 
wall  of  the  stomach  so  as  to  make  it  smaller  (gastroplication).  This 
is  useless,  for  the  size  of  the  stomach  matters  not  at  all ;  the  patient 
is  suffering  from  weakness  of  the  stomach  wall,  with  or  without 
obstruction,  and  in  neither  case  can  good  result. 

INJURIES 

The  stomach  or  duodenum  may  be  injured  by  violence  applied 
from  without,  in  abdominal  contusions  and  wounds ;  or  from  within, 
as  the  result  of  the  passage  of  instruments,  over-distension,  or  the 
action  of  swallowed  corrosive  fluids  or  foreign  bodies. 

RUPTURE   OF    THE    STOMACH 

Uncomplicated  rupture  of  the  stomach  is  an  accident  of  extreme 
rarity.  The  cases  may  be  divided  into  two  groups,  the  "  spontaneous  " 
and  the  traumatic.  In  both  the  rupture  may  be  complete,  involving 
all  the  layers  of  the  stomach-wall,  or  incomplete  :  the  latter  can  be 
subdivided  into  those  involving  the  serous  coat  only;  those  involving 
serous  and  muscular  coats — the  interstitial,  usually  due  to  external 
injuries  ;  and  those  causing  rupture  of  mucosa,  generally  the  result 
of  internal  violence. 

Spontaneous  Rupture  of  the  Stomach 

This  heading  should  cover  only  cases  of  rupture  of  a  presumably 
healthy  organ,  occurring  apart  from  external  violence.  It  has  been 
customary  to  include  ruptures  due  to  lavage  and  distension  with  air, 


332  THE   STOMACH   AND   DUODENUM 

but  these  fall  more  appropriately  into  the  next  group.  It  is  an 
exceedingly  rare  condition,  for  not  more  than  10  cases  have  been 
recorded,  all  of  which  terminated  fatally.  The  rupture  is  usually  at 
the  lesser  curvature,  and  generally  occurs  as  the  result  of  spontaneous 
over-distension  ;   in  at  least  3  of  the  cases  it  followed  vomiting. 

It  is  impossible  to  diagnose  more  than  the  occurrence  of  a  per- 
forative lesion  in  the  upper  abdomen.  Operation  should  be  under- 
taken at  once,  the  rent  in  the  stomach  closed  by  a  continuous  stitch 
of  thin  chromic  catgut  taking  up  all  the  coats,  followed  by  a  continuous 
Lembert  stitch  of  silk,  Pagenstecher,  or  linen  thread. 

Traumatic  Kupture  op  the  Stomach 
These  fall  into  two  groups,  due  to — (1)  direct  violence,   (2)  indi- 
rect violence. 

1.  Direct  Violence 

The  violence  may  affect  the  stomach  (a)  from  without,  as  in 
abdominal  contusions,  or  (6)  from  within,  the  result  of  over-distension 
or  of  the  passage  of  instruments. 

(a)  Complete  rupture  of  the  stomach  from  external  violence  is 
rare  ;  rupture  of  the  stomach  apart  from  injury  to  other  viscera  is 
rarer  still.  Among  270  cases  admitted  to  the  London  Hospital  for 
abdominal  contusion  in  the  ten  years  1899-1908,  the  stomach  was 
ruptured  in  5,  and  in  1  only  of  these  was  it  ruptured  alone,  and  even 
then  the  right  kidney  was  "  bruised."  Gastric  ruptures  usually  occur 
in  "  run-over  "  accidents,  the  wheel  passing  over  the  epigastric  and 
umbilical  regions.  Another  and  rarer  cause  is  localized  injury  to 
the  epigastric  region,  such  as  by  a  kick  from  a  horse  ;  in  this  variety 
the  stomach  is  more  likely  to  suffer  alone.  In  both  it  is  unlikely  to 
be  injured  unless  full. 

Ruptures  from  external  violence  are  usually  situated  in  the  region 
of  the  greater  curvature. 

Treatment. — After  any  abdominal  contusion  the  patient  should 
be  placed  in  bed  and  carefully  watched,  the  pulse  and  temperature 
being  taken  hourly.  No  morphia  should  be  given  until  the  question 
of  operation  has  been  settled,  and  then  only  if  the  patient  has  to  be 
moved  to  hospital  or  nursing-home. 

If  the  abdomen  is  rigid,  or  contains  free  fluid  or  gas,  operation 
should  be  immediate.  If  the  signs  are  inconclusive,  operation  should 
be  undertaken  as  soon  as  it  is  seen  that  the  patient  is  getting  worse 
or  not  rallying  from  the  shock. 

The  rent  should  be  sutured  and  extra vasated  fluid  carefully  sponged 
away.  The  employment  of  drainage  will  depend  upon  the  extent 
of  peritoneal  soiling  or  existent  peritonitis.  If  peritonitis  is  present, 
the  usual  treatment  for  this  condition  must  be  adopted  (p.  569). 


RUPTURE    OF    STOMACH 

Prognosis.  -This  is  extremely  grave;  all  the  cases  treated  at 
the  London  Hospital  have  died.  According  to  Deaver  and  Ashurst, 
only  1  operations  for  traumatic  rupture  "l  the  stomach  have  been 
recorded,  and  ;ill  resulted  in  death.  I  nave  operated  upon  2  i 
one  of  which  was  complicated  by  complete  rupture  of  the  transverse 
portion  of  the  duodenum;  the  patient  lived  four  days  after  closure 
of  both  rents,  and  a1  the  autopsy  no  cause  for  death  was  found.  In 
the  other  the  right  kidney  was  also  ruptured,  and  hsemopericardium 
was  found  post  mortem. 

Diagnosis. — It  is  unusual  for  this  to  be  made  before  open 
It  is  unwise  to  make  any  attempt  at  definite  diagnosis  by  such  mei  as 
as  inflation  with  air.     The  important  point  is  to  decide  that  exploration 
is  necessary. 

As  the  result  of  external  violence  the  stomach  may  be  partially 
ruptured,  its  serous,  muscular,  or  mucous  coats,  alone  or  together, 
being  torn  ;  in  some  cases  a  hematoma  develops  in  the  gastric  wall, 
and  may  be  absorbed,  or  may  form  a  cyst  which  may  become  in- 
fected, and  result  in  an  interstitial  abscess.  Tins  may  rupture  into 
the  stomach,  the  pus  be  vomited,  and  recovery  ensue;  or  into  the 
peritoneal  cavity ;  or,  after  adhesions  have  formed  externally,  may 
discharge,  producing  a  gastric  fistula. 

The  gradual  formation  of  a  swelling  in  the  epigastric  region  fol- 
lowing an  injury  should  lead  to  the  suspicion  of  a  partial  rupture 
of  stomach  and  to  exploration.  Pseudopancreatic  cyst  (Jordan  Lloyd) 
must  be  considered  in  diagnosis. 

An  injury  of  the  mucous  membrane  may  lead  to  the  formation  of 
the  so-called  "  traumatic  ulcer  "  of  the  stomach,  characterized  by  the 
usual  symptoms,  but  as  a  rule  healing  rapidly.  In  a  few  cases  such 
"ulcers"  become  chronic  and  have  given  rise  to  perforation,  haemat- 
emesis,  hour-glass  stomach,  or  gastric  dilatation. 

The  treatment  of  this  condition  is  identical  with  that  of  non- 
traumatic ulcer  (p.  350). 

(b)  Rupture,  complete  or  partial,  may  follow  distension  of  the 
stomach  by  fluid  used  for  lavage,  or  gas  used  in  distending  the  stomach 
for  diagnostic  purposes.  These  cases  are  rare.  One  example  only 
has  occurred  at  the  London  Hospital  in  the  last  ten  years,  in  a  patient 
with  dilated  stomach  the  result  of  pyloric  carcinoma.  During  lavage 
there  was  a  sudden  onset  of  abdominal  pain  and  collapse.  At  operi  - 
tion  five  hours  later  a  rupture  at  the  lesser  curvature  was  found. 
The  patient  died  sixteen  hours  after  operation. 

Ruptures  from  over-distension  occur  most  frequently  at  the  lesser 
curvature,  very  occasionally  at  the  site  of  an  ulcer.  simple  or  malig 
Ruptures  may  also  be  produced  by  the  passage  of  instrument-,  such 
as  the  gastroscope,  for  exploratory  purposes. 


334  THE   STOMACH   AND   DUODEM'M 

If  sudden  pain  and  collapse  follow  the  passage  of  a  stomach-tube 
or  diagnostic-  instrument,  thus  raising  the  suspicion  that  this  accident 
has  occurred,  immediate  operation  must  be  undertaken. 

2.  Indirect   Violence 

Cases  have  been  recorded  in  which  gastric  haemorrhage  has  followed 
falls  on  the  back  or  the  buttocks,  or  after  lifting  heavy  weights.  It 
is  just  possible  that  lesions  of  the  mucous  membrane  may  account 
for  these  cases  ;  from  their  nature  they  do  not  lead  to  post-mortem 
examination.  Bleeding  after  indirect  injury  comes,  in  most  cases, 
from  oesophageal  varices  due  to  cirrhosis  of  the  liver.  All  the  cases 
of  this  nature  that  have  come  under  my  observation,  in  which  there 
was  no  history  of  previous  gastric  trouble,  appeared  to  be  due  to  this 
cause,  but  I  have  known  severe  hsematemesis  follow  indirect  violence 
due  both  to  falls  and  to  strains,  in  patients  with  chronic  gastric  ulcer. 

Injury  may  be  the  exciting  cause  leading  to  the  perforation  of  a 
gastric  or  duodenal  ulcer  ;  several  cases  have  come  under  my  care  in 
which  perforation  occurred  at  the  time  the  patient  was  straining  to 
lift  a  heavy  weight  ;  in  two  cases  in  which  a  duodenal  ulcer  perforated, 
the  patient  had  had  no  previous  gastric  symptoms.  The  onset  of 
sudden  pain  and  acute  abdominal  symptoms  in  circumstances  such  as 
these  should  lead  to  a  suspicion  of  perforation  and  to  immediate 
operation. 

RUPTURE    OF   THE   DUODENUM 

While  rupture  of  the  stomach  is  extremely  rare,  rupture  of  the 
duodenum  is  still  rarer. 

Thus,  out  of  270  eases  of  contused  abdomen  admitted  into  the  London 
Hospital  between  the  years  1899-1908  there  were  19  cases  of  ruptured  gut, 
and  in  these  the  duodenum  was  affected  twice  only.  In  one  case  already 
mentioned  the  stomach  also  was  ruptured  ;  in  the  second  case  no  operation 
was  performed. 

Berry  and  Giuseppi  found  records  of  only  132  cases  of  traumatic  intes- 
tinal rupture  in  ten  London  hospitals  from  1893-1907  ;  the  duodenum  was 
affected  in  23  and  the  duodeno-jejunal  flexure  in  3.  Meerwein,  in  publishing 
(1907)  an  account  of  a  case  under  his  care,  collected  all  the  published  cases 
of  traumatic  rupture  of  duodenum,  64  in  number.  These  include  only  2  of 
those  collected  by  Berry  and  Giuseppi. 

The  transverse  portion  of  the  duodenum  usually  suffers,  the  rent 
being  most  often  at  right  angles  to  the  long  axis  of  the  gut.  As  in 
ruptures  of  the  stomach,  the  lesion  may  be  complete  or  incomplete  ; 
the  latter  is  rare,  but  Berry  records  an  instance  in  a  boy  of  15  in  whom 
'*  a  clot  of  blood  as  large  as  a  hen's  egg  lay  between  the  peritoneal  and 
the  muscular  coats  and  completely,  blocked  the  second  part  of  the 
duodenum/'  The  rupture  may  be  retroperitoneal.  '  This  occurred  in 
4  out  of  the  23  cases  collected  by  Berry  and  Giuseppi. 


RUPTURE    OF    THE    DUODENUM  335 

\    in  other  parts  of  the  alimentary  canal,  partial  rapture  ma 
recovered  from  and  li-.ul  to  obstructive  symptoms  later.     Me< 
records   _  ■    sea  in   which  spontaneous  recovery  occurred,  but  biliary 
obstruction   in   one,  and  dilated  stomach  in  the  other,  necessitated 
operation. 

Diagnosis.  —  lr  will  be  impossible  to  make  a  definite  diagnosis 
of  the  portion  of  the  gut  injured  before  operation.  Rupture  of  the 
duodenum  should  be  suspected  in  all  cases  of  injury  to  the  upper 
abdomen.  Retroperitoneal  injury  should  be  suspected  when  symp- 
toms of  sepsis  follow  an  injury  to  the  upper  abdomen. 

Treatment.- -Tin-  general  rules  which  govern  operation  after 
abdominal  contusions  are  to  be  followed.  Rupture  of  the  duodenum 
should  always  be  borne  in  mind,  and  its  whole  extent  carefully 
examined.  It  was  overlooked  at  operation  in  7  of  Berry  and  Giuseppi's 
and  in  7  of  I  be  29  cases  recorded  by  Meerwein  in  which  operation 
was  performed. 

If  the  rent  involves,  as  is  usual,  the  anterior  wall  of  the  duodenum 
only,  it  should  be  closed  in  two  layers,  the  inner  with  fine  chromic 
gut  through  all  the  coats,  buried  by  fine  silk  Lembert  stitches.  If 
the  rent  is  complete,  gastrojejunostomy  will  be  the  best  course  to 
pursue  after  closure  of  both  ends  of  the  gut.  End-to-end  suture  of 
the  second  or  third  parts  of  the  duodenum  is  unlikely  to  be  successful 
on  account  of  the  absence  of  peritoneum  from  its  posterior  surface. 

Prognosis. — This  is  extremely  grave.  Complete  rupture,  unless 
treated  by  operation,  is  inevitably  fatal.  Death  followed  in  all  the 
cases  recorded  by  Berry  and  Giuseppi,  and  in  all  but  2  of  tl 
recorded  by  Meerwein  in  which  operation  was  performed.  In  only 
1  case  in  this  country  (Godwin's),  operated  on  in  1905,  has  recovery 
followed,  although  a  patient  whom  Moynihan  treated  by  closure  of 
both  ends  and  gastrojejunostomy  lived  104  days  after  operation,  and 
died  as  the  result  of  the  lodgment  of  the  Murphy's  button  used. 

WOUNDS    OF    THE    STOMACH 

The  stomach  may  be  injured  in  penetrating  abdominal  wounds, 
the  result  of  stabs  with  sharp  implements  or  of  gunshots. 

Stab  Wounds 

Wounds  of  the  stomach  are  rare  in  civil  life.  Thus,  in  125  patients 
with  penetrating  wounds  of  the  abdomen  treated  at  the  London 
Hospital  between  1899  and  1908,  in  no  instance  was  the  stomach  injured. 
Among  75  cases  of  wounds  of  the  stomach  collected  by  Siegel,  4  were 
the  result  of  stabs.  Even  when  the  stomach  is  wounded,  the  case  is 
often  complicated  by  simultaneous  injury  to  other  organs. 

The  stomach  may  be  injured  alone  in  stabs  in  the  epigastric  region. 


336  THE   STOMACH   AND   DUODENUM 

and  it  is  important  to  remember  that  stab  wounds  of  the  lower  chest 
are  not  infrequently  complicated  by  injury  to  the  stomach. 

Symptoms. — These  will  depend  to  a  certain  extent  upon  the 
contents  of  the  stomach  at  the  time  of  the  infliction  of  the  injury, 
and  the  size  of  the  wound.  Sudden  leakage  of  gastric  contents  into 
the  peritoneal  cavity  will  be  followed  by  the  usual  signs  accompanying 
perforation  of  an  abdominal  viscus.  In  a  few  cases  the  escape  of 
gastric  contents  from  the  wound,  their  presence  upon  the  instrument 
inflicting  the  injury,  or  hsematemesis  may  render  the  diagnosis  certain. 
But  it  must  be  remembered  that  the  stomach  may  be  wounded  and 
no  symptoms  be  present  at  an  early  stage,  also  that  hsematemesis 
may  occur  from  bruising  or  laceration  of  the  mucous  membrane  of 
the  stomach  without  penetration. 

Treatment. — If  it  is  certain  from  the  symptoms  that  the 
wound  is  a  penetrating  one,  it  should  be  opened  up  and  a  careful 
examination  made,  remembering,  if  a  wound  is  found  on  the  anterior 
surface  of  the  stomach,  that  the  posterior  surface  may  have  been 
simultaneously  damaged.  The  wound  in  the  stomach  should  be  closed 
by  a  continuous  stitch  of  fine  chromic  gut  through  all  its  coats,  this 
being  buried  by  a  Lembert  stitch  of  silk.  Pagenstecher,  or  linen  thread. 
Any  extravasated  contents  should  be  gently  wiped  away.  If  there 
is  extensive  soiling  of  the  peritoneum,  a  tube  should  be  put  in  above 
the  pubes  ;  if  general  peritonitis  is  present,  the  appropriate  treatment 
should  be  adopted. 

Prognosis. — If  operation  is  carried  out  within  the  first  twenty- 
four  hours  the  prognosis  is  good  ;  recovery  took  place  in  8  of  the 
9  recorded  cases. 

Gunshot  Wounds 

It  is  rare  for  the  stomach  to  be  injured  alone  in  wounds  of  this 
nature.  Thus,  out  of  126  cases  collected  by  Forgue  and  Jeanbrau. 
in  which  the  lesion  was  verified  post  mortem  or  by  operation,  in 
only  32  did  it  suffer  alone.  In  about  10  per  cent,  of  these  cases  only 
one  perforation  existed ;  and  in  3  cases  the  bullet  lodged  in  the 
stomach. 

In  wounds  in  war.  from  modern  rifles,  the  bullet  usually  passes 
through  the  body  unless  turned  aside  by  bone.  On  the  other  hand, 
in  the  gunshot  injuries  of  civil  life  the  wounds  are  large  and  the  bullet 
usually  remains  in  the  body. 

Symptoms. — The  most  important  are  shock  and  hsematemesis. 

Diagnosis. — This  may  be  possible  from  the  presence  of  the 
above  symptoms,  but  all  penetrating  abdominal  wounds  in  civil  life 
must  be  explored  even  if  symptoms  are  absent. 

Treatment. — The  abdomen  should  be  opened  through  a  mediaD 


FOREIGN    BODIES  337 

incision,  and  fche  stomach  carefully  examined.  After  suture  of  a  won  ml 
on  the  anterior  surface,  the  posterior  surface  should  be  exposed  bj 
making  a  wide  opening  in  fche  .^astro-colic  omentum.  In  ever 
search  should  be  made  for  injury  to  other  organs.  If  the  diaphragm 
be  simultaneously  wounded,  the  pleural  cavity  should  be  drained. 
It  is  only  in  cases  in  which  the  fact  of  perforation  is  doubtful  that 
fche  bullet  wound  itself  should  come  into  the  incision. 

FOREIGN  BODIES  IN  THE   STOMACH   AND  DUODENIM 

The  patients  are  usually  children,  hysterical  girls,  insane  people, 
and  jugglers.  Occasionally  a  foreign  body  such  as  a  tooth-plate  or 
a  piece  of  bone  is  swallowed  by  sane  adults. 

The  majority  of  foreign  bodies  swallowed  pass  out  of  the  stomach, 
and  are  discharged  naturally  a  few  days  later.  A  few,  depending  on 
their  size  and  shape,  may  lodge  in  the  stomach,  or  in  rare  cases  in  the 
duodenum.  The  foreign  body  may  remain  in  the  stomach  for  years 
without  giving  rise  to  symptoms,  or  it  may  perforate  acutely,  or 
cause  ulceration,  subacute  perforation,  perigastric  abscess,  or  gastric 
fistula . 

In  children  and  the  insane  no  history  may  be  obtainable,  and  the 
onset  of  vomiting  and  pain  causes  attention  to  be  directed  to  the 
stomach.  The  finding  of  a  foreign  body  in  the  vomit  may  lead  to 
a  diagnosis  of  the  cause  of  the  symptoms. 

The  foreign  body  may  be  composed  of  hair,  the  so-called  hair-ball. 
In  these  cases  the  patient  or  friends  may  fail  to  connect  the  habit  of 
hair-biting  with  the  abdominal  signs,  and  the  surgeon  may  omit  to 
consider  this  possibility,  but  in  all  obscure  abdominal  tumours  in 
women  it  should  be  remembered.  These  tumours  are  rarely  found 
in  men,  and  are  uncommon  in  the  insane.  In  42  cases  collected  by 
Butterworth,  39  were  females. 

The  quantity  of  hair  present  varies  :  in  one  case  operated  upon 
successfully  by  Swain,  it  weighed  5  lb.  3  oz.  The  mass  can  usually 
be  felt  through  the  abdominal  wall.  When  small  it  occupies  the 
pyloric  region,  but  as  it  increases  in  size  it  forms  a  cast  of  the  stomach 
which  may  in  rare  cases  extend  into  the  oesophagus  or  into  the 
duodenum  (Fig.  371).  Symptoms  may  be  absent,  and  the  abdominal 
tumour  be  discovered  by  accident.  As  a  rule,  however,  pain  and 
vomiting  are  present  after  food.  The  tongue  is  foul,  and  the  patient 
is  usually  anaemic. 

Fenwick  states  that  the  average  duration  of  the  disease  in  these 
cases  is  about  fifteen  years.  All  end  fatally,  unless  operated  upon, 
from  ulceration  and  perforation  of  the  stomach  and  its  sequelae, 
cr  from  exhaustion. 

Concretions    formed    of   vegetable    fibres    are    occasionally    found, 


333  THE   STOMACH   AND   DUODENUM 

usually  in  patients  who  have  chewed  roots  which  have  reputed 
medicinal  properties ;  and  gastroliths  in  patients  who  have  drunk 
varnish  in  their  craving  for  alcoholic  liquor.  The  gastrolith  is  usually 
composed  of  shellac.  According  to  Fenwick,  only  4  cases  have  been 
recorded. 

Treatment. — This  will  depend  on  the  form,  consistence,  and  size 
of  the  article  swallowed.  Rounded  objects,  coins,  buttons,  etc.,  usually 
give  rise  to  no  trouble  ;  tooth-plates  and  pencils  rarely  pass.  If  it 
is  thought  that  the  foreign  body  is  likely  to  pass,  a  diet  of  porridge 


c- 

jjji 

^^^^ppr 

Fig.  371. — Hair-ball  removed  from  the  stomach.        //.  .1/.  Rigbfs  case. 

(London  Hospital  Museum.) 

or  mashed  potatoes  should  be  given,  but  no  purgatives.  The  patient 
should  be  X-rayed,  and  the  exact  location  of  the  foreign  body  deter- 
mined. It  must  be  remembered  that  its  weight  may  displace  the 
stomach,  and  it  may  be  necessary  to  use  X-rays  after  bismuth 
emulsion  has  been  taken.  If  the  foreign  body  is  giving  rise  to  no 
symptoms,  no  hurry  is  necessary. 

If  natural  discharge  is  impossible,  from  the  size,  shape,  or  number 
of  foreign  bodies,  or  if  symptoms  are  produced,  immediate  operation 
should  be  resorted  to. 

In  most  cases  it  will  be  necessary  to  open  the  stomach  after  packing 
off  the  peritoneal  cavity  with  gauze.  The  incision  in  the  stomach 
should  be  transverse  to  its  long  axis,  and,  after  removal  of  the  foreign 
body,  should  be  clo?ed  with  a  continuous  stitch  of  fine  chromic  gut 
through  all  its  coats,  and  this  buried  with  a  continuous  Lembert  stitch 
of  fine  silk.     It  may  be  possible  to  remove  the  foreign  body,  after  the 


INJURY    FROM    CAUSTICS  339 

abdomen  has  been  opened,  by  means  of  forceps  such  as  Briining'a 
ox  Bilton  Pollard's. 

h  the  foreign  body  is  in  the  duodenum,  an  attempl  Bhould  be 
made  to  push  it  back  into  the  stomach  and  extract  it  from  there  ; 
only  if  this  fails  should  the  opening  be  made  in  the  duodenum. 

Prognosis.  This  is  extremely  good.  Out  of  20  cases  published 
since  1900,  and  collected  by  Deaver  and  Ashurst,  in  which  operation 
was  performed,  there  was  only  1  death. 

INJURY    BY    CAUSTIC    FLUIDS 

Mineral  acids  and  alkalis,  swallowed  by  accident  or  with  suicidal 
intent,  cause  serious  injury  to  the  stomach.  In  many  of  these  cases 
surgical  treatment  is  sooner  or  later  necessary  to  remedy  the  resulting 
contraction-deformities  of  the  stomach.1 

The  cardiac  end  and  pyloric  portion  of  the  stomach  suffer  most, 
and  in  some  cases  the  latter  is  alone  injured. 

The  stomach  is  markedly  affected  if  a  large  quantity  of  corrosive 
fluid  has  been  swallowed  and  the  stomach  is  empty.  Vomiting  is 
incessant,,  and  the  vomit  contains  blood  and  is  often  foul-smelling. 
In  two  cases  the  smell  was  so  offensive  that  I  was  asked  to  see  the 
patients  as  examples  of  gastro-colic  fistulse.  Thirst  is  marked,  rest- 
lessness is  extreme,  and  many  patients  succumb  in  the  early  stages 
to  lung  complications. 

Perforation  may  take  place.  This  is  stated  to  occur  most  fre- 
quently after  alkalis,  an  unusual  form  of  corrosive  poisoning  in 
London.  Of  the  12  cases  of  perforation  recorded  in  the  footnote  below, 
11  occurred  after  hydrochloric  acid,  being  nearly  half  the  fatal  cases. 

Treatment. — After  the  appropriate  antidote  has  been  given, 
rectal  feeding  must  be  employed  and  no  food  given  by  the  mouth. 
If  there  are  ulcerated  surfaces  in  the  mouth  and  pharynx,  these  should 
be  kept  clean  by  mild  antiseptic  solutions. 

After  a  few  days,  feeding  should  be  cautiously  begun.  Small 
quantities  of  albumin  water  should  be  first  tried,  and,  if  this  causes 
no  pain  or  vomiting,  Benger's  or  Allenburys'  food  may  be  given.  If 
at  the  end  of  about  a  week  it  is  found  that  the  introduction  of  food 
causes  pain  and  vomiting,  operation  should  be  performed  without 
delay.  In  most  cases  jejunostomy  will  be  necessary,  but  if  the  lesion 
proves  to  be  confined  to  the  pyloric  portion  of  the  stomach,  gastro- 
jejunostomy should  be  performed. 

1  Oases  of  caustic-swallowing  admitted  to  London  Hospital  in  the  decen- 
nium  L899-1908 — total.  1S9.  Deaths  within  a  few  days,  35— of  these  12  died  of 
ric  perforation  (11  HC1,  1  carbolic);  and  8  cases  required  operations  for 
mechanical  disabilities  within  a  few  months,  viz.  4  for  pyloric  stenosis,  3  for 
oesophageal  stricture,  and  1  for  both.  There  is  no  doubt  that  8  out  of  154  greatly 
understates  the  frequency  of  late  surgical  complications. 


340  THE   STOiWACH   AND   DUODENUM 

In  less  severe  eases  it  not  infrequently  happens  that,  after  five  or 
six  weeks,  signs  of  cardiac  or  pyloric  obstruction  develop.  The  appro- 
priate operation  should  be  done — in  the  former  case  gastrostomy,  in 
the  latter  gastrojejunostomy.  It  sometimes  happens  that  hour-glass 
stomach  develops.  This  should  be  treated  on  the  usual  lines  (p.  324). 
Gastrojejunostomy  will  suffice  in  most  cases,  as  the  pyloric  pouch 
is  small. 

GASTRIC  AND  DUODENAL  ULCERS 

The  stomach,  and  the  duodenum  as  far  as  the  entrance  of  the 
common  bile-duct,  are  frequently  the  seat  of  ulcers,  which  are  identical 
so  far  as  their  anatomical  features  are  concerned,  and  probably  caused 
in  a  similar  manner  ;  it  is  customary  to  classify  them  as  acute  and 
chronic. 

GASTRIC   ULCER 

Etiology. — Gastric  ulcer  is  an  extremely  common  condition. 
Brinton's  statement  that  a  "  peptic  "  ulcer,  open  or  healed,  was  present 
in  5  per  cent,  of  all  autopsies  has  been  confirmed  by  Welch  and 
Greenhough  and  Joslin.  It  is  more  common  in  northern  climates, 
and  in  England  than  in  Europe. 

Sex  and  age — It  was  at  one  time  customary  to  consider  gastric 
ulcer  essentially  a  disease  of  women.  In  the  cases  diagnosed  clinically 
the  proportion  is  about  75  females  to  25  males.  But  since  the  develop- 
ment of  the  surgery  of  the  stomach  our  ideas  have  undergone  a  change, 
for  in  many  cases,  diagnosed  clinically  as  gastric  ulcer,  particularly  in 
young  women,  no  ulcer  was  found ;  for  these  Hale  White  suggests  the 
name  gastrostaxis  ;  according  to  Sir  Bertrand  Dawson,  some  of  them 
proved  to  be  septic  gastritis.  If  these  cases  are  excluded,  it  is  found 
that  the  frequency  is  only  slightly  greater  in  women  than  in  men. 

During  the  ten  years  1899-1908,  343  patients  with  gastric  ulcer  in  whom 
the  diagnosis  was  confirmed  by  operation  or  post  mortem  were  treated  in 
the  London  Hospital ;  of  these  199  were  women  and  144  men.  Perforation 
had  occurred  in  136  of  these  cases,  92  of  which  were  those  of  women.  This 
about  corresponds  with  the  figures  given  by  Brinton  for  perforated  ulcers — 
twice  as  common  in  women  as  in  men.  Of  the  chronic  ulcers  operated  upon 
for  causes  other  than  perforation,  the  numbers  were  almost  equal :  women 
107,  men  100.  Of  28  patients  with  perforated  ulcer  personally  operated 
upon  up  to  December,  1911.  13  were  men;  but  of  the  patients  operated 
upon  for  chronic  ulcer,  97  in  number,  in  all  of  whom  a  definite  ulcer  was 
demonstrated,  60  were  men.  In  addition,  I  have  explored  the  stomach  in 
11  patients,  all  women  with  symptoms  of  gastric  ulcer,  and  found  no  gastric 
lesion ;   such  cases  have  by  some  been  described  as  "  medical  ulcers." 

It  is  safe  to  say  that  acute  perforating  ulcer  is  more  usually  met  with 
in  women,  but  that  the  chronic  ulcer  needing  surgical  treatment  is  more 
common  in  men. 

Gastric  ulcer  is  a  disease  of  adult  life  ;    although  isolated  cases  have  been 


GASTRIC   ULCER:    ETIOLOGY  341 

recorded  in  children  and  in  old  people,  yet  the  majority  ooonr  between  the 
ages  of  20  and  46.  Among  the  London  Hospital  oasee  of  perforated  gastri 
nicer  the  yoongeel  patient  was  ■">  yean,  the  oldeel  was  si  ;  bul  the  condition 
has  been  recorded  in  a  centenarian,  and  in  infante  ol  r>  boura,  2  months, 
and  1  year  respectively. 

Bfayo  Robson  states  that  in  women  7">  per  rent,  of  the  cases  are  found 
before  the  age  of  20,  whilst  in  men  only  26  per  cent,  occur  so  early;  these 
figures  agree  with  those  at  the  London  Eospital.  Perforation  occurs  later 
in  men  than  in  women;  for  example,  in  !t-J  consecutive  cases  of  perforated 
gastric  ulcer  in  women  at  the  London  Eospital,  55  occurred  between  the 
5  20,  whilst  of  44  in  men  only  6  occurred  during  this  period,  14  between 
25  and  35,  and  13  between  35  and  4").  In  women  the  greatest  number  of 
chronic  eases  are  treated  between  the  ages  25  35  (43  out  of  107).  in  men 
between  35-45  (42  oul  of  LOO).  Jt  is  evident,  therefore,  thai  chronic  gastric 
nicer  is  most  often  met  with  in  adult  life,  in  men  later  than  in  women. 

Immediate  etiology. — In  discussing  the  causation  of  gastric 
ulcer,  gastric  erosions  and  acute  and  chronic  ulcers  must  be  considered 
together. 

Certain  observations,  experimental  and  clinical,  stand  out  pro- 
minently. It  has  been  found  possible  to  produce  gastric  ulcers  experi- 
mentally by  methods  which  will  lead  to  ulceration  in  other  parts  of 
the  body,  as  the  result  of  injury  to  the  mucous  membrane,  injury 
to  nerves,  embolism  and  thrombosis,  and  local  infection  ;  but  as  a 
rule  the  ulcers  so  produced  heal  rapidly. 

Bolton  has  shown  that  gastric  ulcers  are  due  to  the  action  of  the 
gastric  juice  upon  devitalized  gastric  mucous  membrane.  By  injecting 
into  guinea-pigs  gastrotoxic  serum  prepared  by  injecting  the  gastric 
cells  of  the  guinea-pig  into  the  rabbit,  areas  of  necrosis  and  punched- 
out  ulcers  were  produced.  The  formation  of  these  could  be  prevented 
by  neutralizing  the  gastric  juice  with  20  c.c.  of  a  1  per  cent,  solution 
of  bicarbonate  of  soda.  Hyperacidity  of  the  gastric  juice  alone  would 
not  produce  ulcers,  but  any  excess  of  hydrochloric  acid  increased  the 
lesion  produced  by  the  injection  of  gastrotoxic  serum.  The  injection 
of  hepatotoxin,  enterotoxin,  and  hemolysin  also  produced  necrotic 
patches  in  the  mucous  membrane  of  the  stomach  indistinguish  ble 
from  those  produced  by  gastrotoxin.  A  chronic  ulcer  could  not  be 
produced  either  by  repeated  injections  of  gastrotoxin,  by  increasing 
the  percentage  of  hydrochloric  acid,  or  by  feeding  on  infected  food ; 
but  motor  insufficiency  of  the  stomach  delayed  healing  for  at  least 
twice  the  normal  time,  and  when  the  ulcer  healed  the  mucous  membrane 
was  of  a  lower  type  than  normal.  Turck  has  been  able  to  produce 
gastric  and  duodenal  ulcers  in  dogs  by  feeding  them  for  prolonged 
periods  on  food  containing  cultures  of  the  colon  bacillus.  When  the 
feeding  was  stopped  the  ulcers  healed. 

There  are  certain  pathological  and  clinical  data  bearing  on  the 
subject. 


342 


THE   STOMACH   AND   DUODENUM 


C.  H.  Miller  has  stated  that  lymphoid  follicles  are  grouped  chiefly 
at  the  lesser  curvature  and  in  the  pyloric  region,  and  tend  to  disappear 
between  the  ages  of  45-50 ;  that  as  the  result  of  infection  they  may 
become  swollen  and  eroded,  leading  in  many  cases  to  hsematemesis. 
In  examining  the  non-ulcerated  portions  of  the  stomach  in  cases  of 
gastric  ulcer,  he  found  a  great  increase  in  the  amount  of  lymphoid 
tissue  present,  an  enlargement  of  the  individual  follicles,  and  a  thicken- 
ing of  the  submucous  layer.  He  believed  that  these  changes  might 
be  a  factor  in  the  non-healing  of  an  acute  ulcer  which  was  due  to 
a  follicular  erosion. 

Erosions  and  ulcers  of  the  stomach  and  duodenum  are  found  in 
many  acute  diseases — in  erysipelas,  septicsemia,  local  septic  infections, 

genito-urinary  affections,  burns, 
etc.  During  the  years  1907, 
1908,  and  1909,  26  acute  ulcers 
were  found  in  the  stomach 
and  4  in  the  duodenum  in 
autopsies  performed  at  the 
London  Hospital  on  patients 
dying  from  causes  other  than 
gastric. 

In  these  26  cases  the  cause  of 
death  was  as  follows  :  Suppurative 
appendicitis,  12  ;  pylephlebitis,  2 ; 
gangrene  of  the  foot,  2 ;  chronic 
nephritis,  2  ;  ulcerative  endocard- 
itis, 2  ;  intestinal  obstruction,  2  ; 
carcinoma  of  gall  -  bladder,  2  ; 
puerperal  septicaemia,  lobar  pneu- 
monia, and  mitral  stenosis,  1 
each.     {See  Fig.  372.) 

Hort  considers  that  gastric  and  duodenal  ulcers  are  the  local 
expression  of  a  general  blood  disease. 

"  Peptic  "  ulcers  are  only  found  in  those  parts  of  the  intestinal 
canal  in  which  the  contents  are  acid.  Bolton's  experiments  on  the 
production  of  gastric  ulcer  showed  that  excess  of  hydrochloric  acid 
delayed  healing.  In  most  cases  of  chronic  gastric  ulcer,  as  has  been 
emphasized  lately  by  Willcox,  the  total  acidity  is  high  ;  this  is  pro- 
bably a  factor  in  the  initial  development  of  the  ulcer,  but  when  the 
ulcer  has  become  chronic  this  high  acidity  is  not  invariably  found. 

These  considerations  lead  me  to  the  belief  that  acute  gastric  ulcers 
are  due  to  the  autodigestion  of  areas  of  gastric  mucous  membrane, 
the   resistance  of   which    has    been    lowered    as  the    result   of   toxic . 
products  acting  directly  on  the  gastric  cells  or  giving  rise  to  a  swelling 
and  erosion  of  lymphoid  follicles.     Chronic  appendicitis  is  probably! 


Fig.  372.  —  Acute  duodenal  ulcer 
found  post  mortem  in  a  child  of 
3;V  who  died  of  gangrene  of  the 
leg  following  a  crush. 


GASTKIC    ULCER:    ETIOLOG1 


343 


a  Erequenl  source  of  the  septic  infection.    The  Lowered  resistance  of 

i  be  gastric  mucous  membrane  may  possibly  in  some  oases  be  produ  i  d 
by  obstruction  of  small  vessels  either  by  emboli  or  by  thrombosis. 

The  reason  for  the  chronicitij  of  ulcers  is  less  clear,  as  is  also 
the  cause  of  their  greater  frequency  in  males.  Tin's  latter  may  be 
related  to  the  greater  prevalence  of  disease  of  the  appendix  in  the 


Fig.  373. — "  Saddle-shaped  "  ulcer  of  lesser  curvature,  with 
pancreas  exposed  on  the  floor  of  its  posterior  portion. 

(London  Hospital  Pathological  Institute.} 


male  sex.  Oral  sepsis  is  present  in  most  patients  with  chronic 
gastric  ulcer ;  Mayo  Robson  believes  that  this  is  an  important 
causal  condition  in  a  large  number  of  cases.  Few  theories  seem  to 
fit  in  with  the  established  fact  that  these  ulcers  heal  after  gastro- 
jejunostomy. The  cause  of  non-healing  may  be  continual  irritation 
by  abnormal  gastric  juice  or  by  retention  of  food  in  the  stomach 
owing  to  pyloric  spasm. 

Acute  gastric   ulcers   are   often   multiple    (according    to    Brinton, 


344 


THE  STOMACH   AND   DUODENUM 


more  than  one  ulcer  is  present  in   21   per  cent,  of  the  cases),  but 
chronic  gastric  and  duodenal  ulcers  are  usually  single. 

Site — Ulcers  of  the  stomach  are  usually  situated  on  the  lesser 
curvature  towards  the  pylorus,  and  involve  more  often  the  poste- 
rior than  the  anterior  wall.  Those  which  are  situated  on  the  lesser 
curvature  not  infrequently  involve  both  walls  and  constitute  the  so- 
called  "  saddle  "  ulcers  (Fig.  373).  The  acute  ulcers  which  perforate 
are  most  often  situated   on   the   anterior   wall    (Fig.   375). 

Morbid     anatomy 

The  acute  ulcer  sometimes 
called  "  round "  is  well  de- 
fined and  has  a  punched-out 
appearance.  In  shape  it  is 
conical,  the  deeper  layers  being 
affected  to  a  less  extent  than 
the  mucous  membrane.  The 
floor,  usually  formed  of  the 
muscular  coat,  is  not  covered 
with  granulations,  and  post 
mortem  no  peritoneal  affec- 
tion is  found.  Microscopical 
examination  reveals  necrosis 
without  any  special  infiltration 
with  small  lymphocyte  -  like 
cells  or  granulation  tissue  cells, 
and  the  mucous  membrane  is  usually  healthy  right  up  to  the  margin 
of  the  ulcer. 

In  cases  of  acute  ulcer  leading  to  perforation,  as  seen  at  operation, 
the  surrounding  stomach  wall  may  be  cedematous,  but  this  condition 
is  absent  post  mortem,  and  is  not  marked  if  operation  is  performed 
within  a  short  time  after  the  perforation. 

The  edge  of  a  chronic  ulcer  is  often  irregular,  indurated  and 
smooth,  and  the  floor  covered  with  scattered  granulations.  Satellite 
acute  ulcers  are  sometimes  present.  The  peritoneum  covering  it 
is  thickened,  and  adhesions  are  often  met  with.  When  seen  during 
life  the  peritoneum  is  rough  and  often  red-speckled,  and  there  is 
frequently  a  "  sentinel "  enlarged  lymphatic  gland  between  the  layers 
of  the  neighbouring  omentum.  Adhesions  to  surrounding  organs  may 
take  place,  and  in  this  way,  with  a  continuance  of  the  ulcerative  pro- 
cess producing  destruction  of  the  stomach  wall,  the  floor  of  the  ulcer 
may  be  formed  of  pancreas  or  of  liver.  Blood-vessels  may  be  laid 
bare,  and  the  consequent  weakening  of  their  coats  may  lead  to  the 
formation  of  an  aneurysm  and  to  fatal  hcematemesis  (Fig.  376). 
Symptoms. — The  most  striking  feature  in  connexion  with  the 


Fig.  374. — Diagram  showing  the  situa- 
tion of  the  ulcer  in  Fig.  373. 


(i  \STKIC    ULCER  :    SYMPTOMS 


345 


symptoms  * » f  chronic  gastric  and  chronic  duodenal  ulcers  is  bheii 
remission.  In  the  former,  severe  attacks  of  pain  and  vomiting,  lasting 
for  a   few  days  or  weeks,  intermit  with  periods  <>i   almost  though 

rarely  quite  perfect  digestive  health;  whilst  in  duodenal  nice]'  the 
patient   may  experience  months  of  perfect  health  before  the  unset  of 

another   attack. 

Savaiiaud  has  stated  that 
20  per  cent,  of  ulcers  are 
latent  ;  these  are  frequently 
on  the  Lesser  curvature,  lint 
this  percentage  is  far  too 
high  ;  that  gastric  ulcers  are 
common  without  the  so-called 
classical  symptoms  is  now- 
well  established,  but  few  are 
really  "latent."  The  classical 
symptoms  are  pain,  vomiting, 
ha'inatemesis.  Pain  is  the 
most  prominent  feature,  and 
is  rarely  absent.  It  is  closely 
associated  with  the  ingestion 
of  food ;  it  usually  appears 
within  an  hour  of  a  meal, 
there  is  always  a  definite  latent 
period,  and  the  pain  persists 
until  the  stomach  is  emptied 
naturally  or  by  vomiting.  The 
pain  is  of  a  stabbing  or  burn- 
ing character,  situated  in  the 
epigastric  region. 

On  account  of  the  frequent 
multiplicity  of  the  lesions  and 
complications,  dogmatic  state- 
ments are  impossible  regard- 
ing the  relationship  of  the 
situation  of  the  pain  and  tenderness,  and  the  time  at  which  it 
appears,  to  the  situation  of  the  ulcer.  But  it  can  be  stated  that 
in  ulcers  on  the  posterior  surface  and  lesser  curvature  the  pain  is 
usually  to  the  left  of  the  middle  line,  and  that  the  nearer  the  cardiac 
end  of  the  stomach  the  lesion  is  situated  the  higher  in  the  epigastric 
region  is  the  site  of  the  pain.  This  fact  was  first  pointed  out  by 
Brinton,  and  stress  has  lately  been  laid  on  it  by  James  Mackenzie. 
In  pyloric  ulcer  the  pain  tends  to  appear  later,  and  to  be  to  the 
right  of  the  middle  line.     In  some  cases  of  chronic  idcer  situated  on 


Fig.  375. — Multiple  acute  gastric  ul- 
cers, one  of  which  has  perforated. 
The  stomach  has  been  opened 
along  its  greater  curvature.  The 
ulcer  which  has  perforated  is  on 
the  anterior  surface,  and  shows 
the  typical  characteristics  of  an 
acute  ulcer. 

[London  Hospital  Pathological  Institute.) 


346 


THE   STOMACH   AND   DUODENUM 


the  lesser  curve  the  pain  appears  late,  and  is  definitely  relieved  by 
taking  food.  The  pain  may  be  referred  to  the  left  dorsal  region, 
and  not  infrequently,  in  an  ulcer  of  the  anterior  surface,  to  the  left 
shoulder. 

The  pain  is  often  associated  with  tenderness,  superficial  and  deep 
(see  p.  303).  Superficial  tenderness  is  uncommon,  and  is  found  in 
other  gastric  conditions  ;  it  most  often  extends  as  a  band  around 
the  body  at  the  level  of  the  8th  and  9th  dorsal  segments.  Deep 
tenderness  in  the  epigastric  region  is  usual,  and  is  accompanied  by 

rigidity  of  the  rectus 
muscle  ;  in  ulcers  of  the 
cardiac  end  it  is  most 
often  met  with  over  the 
upper  part  of  the  left 
rectus,  in  those  of  the 
pylorus  over  a  similar  part 
of  the  right  rectus. 

A  patch  of  tenderness 
is  sometimes  present  in 
the  dorsal  region  to  the 
left  of  the  9th  and  10th 
dorsal  spines. 

In  a  large  proportion 
of  cases  of  chronic  ulcer, 
free  HC1  and  the  total 
acidity  of  the  gastric  con- 
tents are  increased  slightly 
in  amount,  or  only  little 
altered  from  the  normal ; 
but  cases  occur  in  which  free  HC1  is   diminished. 

Vomiting  is  usual  at  some  time  during  the  course  of  the  disease, 
and  may  be  one  of  its  most  prominent  features.  Its  occurrence 
relieves  the  pain  experienced  from  the  ingestion  of  food.  The  emesis 
may  be  self-induced,  but  this  is  more  often  the  case  when  the  ulcer 
is  duodenal.  It  must  not,  however,  be  forgotten  that  vomiting  is 
infrequent  in  many  cases  of  chronic  ulcer. 

Bleeding  into  the  stomach  takes  place  in  the  majority  of  cases 
of  gastric  ulcer.  Although  it  produces  hsernatemesis  in  only  about 
50  per  cent,  of  the  cases,  microscopical  examination  of  the  vomit  or 
foeces  will  prove  its  existence. 

Anaemia  may  be  present  in  patients  with  acute  and  also  with 
long-standing  chronic  ulcers. 

Occasionally  a  definite  tumour  is  felt,  resembling  that  discovered 
in  carcinoma  of  the  stomach.     There  is  no  certain  means  of  differentia- 


Fig.  376. — Portion  of  posterior  wall  of 
stomach,  showing  a  chronic  ulcer 
which  had  eroded  the  splenic  artery. 

(London  Hospital  Museum.) 


GASTRIC   ULCER!    DIAGNOSIS 

tion,   1ml    examination   of   the  stomach    contents  after  a    tesl    meal 
may  give  valuable  help  (see  p.  .'is;). 

Complications.  The  following  are  the  important  compli- 
cations: (1)  Perforation,  acute  and  chronic  (p.  353) ;  (2)  baematemesis ; 
(3)  pyloric  stenosis  (see  p.  '■'>-')  ;  (1)  hour-glass  stomach  (see  p.  321)  : 
(."))  perigastritis  (p.  358);  (6)  gastric  fistula,  internal  and  external 
(see  p.  !<>1)  ;    (7)  carcinoma  of  stomach  (see  p.  .'ITS). 

Diagnosis. — If  a  patient  presents  the  symptoms  of  epigastric 
pain  originating  a  short  time  alter  food,  relieved  by  vomiting,  and 
especially  if  lie  has  haanat  emesis,  he  is  suffering  from  a  definite  lesion 
of  the  mucous  membrane  of  the  stomach,  in  the  form  of  either  an 
erosion  or  an  ulcer.  It  must,  however,  be  remembered  that,  as  shown 
by  clinical  observations  and  by  the  experiments  of  Bolton,  lesions 
of  the  mucous  membrane  of  the  stomach  occur  in  many  diseases, 
and  may  present  all  the  symptoms  of  ulcer.  It  should  also  be  borne 
in  mind  that  although  the  alimentary  tract  is  divided  for  convenience 
of  description  into  many  parts,  it  is  a  whole,  and  that  interference 
with  the  functions  of  any  one  section  may  cause  trouble  in  the 
others. 

When  the  symptoms  occur  in  young  women,  considerable  doubt 
should  exist  as  to  whether  we  are  dealing  with  a  case  of  true  gastric 
ulcer.  Young  anaemic  women  often  have  pain  after  food,  and  vomit, 
with  occasional  bsematemesis,  yet  their  symptoms  are  certainly  not 
in  the  majority  of ''cases  due  to  an  ulcer,  using  the  term  in  its  usual 
significance. 

There  is  a  group  in  which  hsematemesis  is  a  prominent  symp- 
tom, called  by  Sir  Bertrand  Dawson  "  hsemorrhagic  gastralgia," 
identical'with  that  described  by  Hale  White  under  the  term  "  gastros 
taxis."  These  cases  are  not  necessarily  associated  with  anaemia, 
and  although  uncommon  after  40,  and  most  frequently  met  with  in 
young  women,  may  occur  at  any  age  and  in  the  male  sex.  In  some 
examined  at  operation  and  post  mortem  no  ulcer  has  been  found. 
But  in  many  cases  "  erosions  "  have  been  present,  seen  during  life, 
but  escaping  observation  post  mortem  unless  the  stomach  is  examined 
with  a  lens.     Hsematemesis  may  be  the  first  symptom  (see  p.  369). 

Apart  from  these  cases  in  which  pain,  vomiting,  and  baematemesis 
occur,  there  are  others  in  which  the  symptoms  are  atypical,  but  which 
frequently  prove  to  be  due  to  chronic  gastric  ulcer.  These  diagnostic 
difficulties  most  often  occur  in  women,  but  are  not  unknown  in 
men.  I  have  explored  11  such  cases,  in  all  of  which  symptoms  had 
persisted  for  over  three  years.  All  had  undergone  systematic  medi- 
cal treatment.  All  were  women  ;  4  had  had  hsematemesis,  all  pain 
after  food  was  relieved  by  vomiting.  All  were  operated  upon  as  cases 
of  chronic  gastric  ulcer,  although  in  2  only  did  the  operative  findings 


348  THE   STOMACH   AND   DUODENUM 

come  as  a  surprise.  Their  ages  were  23,  24  (2),  25,  26,  34,  35,  37,  41, 
47,  61,  respectively.  In  none  was  a  definite  stomach  lesion  present, 
and  in  all  the  gall-bladder  and  appendix  were  healthy.  Xo  patient 
was  the  worse  for  exploration,  and  in  the  majority  there  was  an 
improvement. 

Even  where  the  typical  symptoms  are  present,  particularly  in 
women,  the  greatest  care  in  examination  must  be  taken.  It  must 
always  be  remembered  that  disease  of  the  gall-bladder  and  of  the 
colon  or  the  appendix  may  cause  "  dyspepsia."  The  stomach  symp- 
toms associated  with  tabes,  and  with  uraemia  and  diseases  of  the 
bladder  and  urethra,  should  be  recognized,  for  gastrojejunostomy 
has  been  performed  on  more  than  one  patient  suffering  from  these 
complaints.  A  careful  study  of  the  patient  will  ensure  diagnosis  of 
the  last  three  groups,  but  no  amount  of  careful  study  can  at  present 
prevent  exploration  in  certain  cases. 

In  the  differential  diagnosis  there  are  six  conditions  requiring 
special  study  :  (1)  Gall-stones  ;  (2)  gastric  crises  of  tabes  ;  (3)  duo- 
denal ulcer ;  (4)  appendicitis  ;  (5)  carcinoma  ;  (6)  diseases  of  the 
colon. 

Gall-stones — It  cannot  be  too  often  repeated  that  the  "text- 
book symptoms "  of  cholelithiasis  are  late  symptoms,  and  that  a 
large  number  of  patients  with  stones  in  the  gall-bladder  have  no 
attacks  of  colic,  but  suffer  from  gastric  symptoms,  and  are  treated 
for  "gastritis,"  "flatulent  dyspepsia,"  or  "gastric  ulcer."  It  is  no 
uncommon  thing  to  find  that  a  patient  with  gall-stones  has  been 
treated  for  acute  gastritis  or  gastric  ulcer^  Kraus  in  1884  described 
the  early  symptoms,  and  recently  Moynihan  and  Mayo  Robson  have 
again  laid  stress  upon  them.  These  "  inaugural  symptoms  "  of  gall- 
stones are  referred  to  the  stomach  ;  the  patient  complains  of  pain 
or  discomfort  within  an  hour  of  taking  food,  relieved  by  belching  or 
vomiting.  There  may  be  a  feeling  of  chilliness  after  a  meal,  parti- 
cularly in  the  evenings.  In  these  cases  there  is  not  the  same  re- 
gularity in  the  occurrence  of  pain  after  meals  as  in  gastric  ulcer, 
and  vomiting  is  more  often  associated  with  frequent  retching,  and 
does  not  so  frequently  relieve  the  pain.  Careful  investigation  will 
usually  enable  a  diagnosis  to  be  made. 

Tabes. — The  gastric  crises  of  tabes  may  cause  difficulty  in 
diagnosis,  particularly  when  they  occur  early  in  the  disease,  before 
the  appearance  of  pupil-changes  or  the  loss  of  knee-jerks.  In  most 
cases,  however,  definite  signs  of  tabes  are  present.  The  symptoms 
are  usually  attacks  of  epigastric  pain,  often  with  rigidity  and  hyper- 
algesia, accompanied  by  the  vomiting  of  large  quantities  of  fluid.  It 
is  a  condition  that  should  be  considered  in  all  anomalous  stomach 
cases. 


GASTRIC:   ULCER:    DIFFERENTIAL    DIAGNOSIS  34f< 

Appendicitis. — Cases  have  come  tinder  the  care  of  mosl  Bur- 
geons in  winch  patients,  after  having  been  treated  several  years  toi 
"dyspepsia,"  develop  an  attack  of  acute  appendicitis.  In  the  early 
days  of  gastric  surgery  there  is  no  doubt  that  cases  of  this  nature 
were  treated,  without  curative  result,  by  gastrojejunostomy.  The 
symptoms  may  date  from  an  acute  attack  of  appendicitis,  but  as  a 
rule  no  acute  attack  has  been  experienced,  and  there  may  have 
been  no  local  symptoms  pointing  to  appendicular  disease.  Until 
recently  this  condition  has  attracted  little  attention  in  this  country, 
but  papers  on  the  subject  have  lately  appeared  from  Moynihan. 
Paterson,  and  Soltau  Fenwick  ;  it  was  recognized  some  years  ago  by 
Kuald.  and  in  America  has  been  written  about  by  Deaver,  Ochsner, 
Murphy,  and  others.  The  symptoms  may  mimic  either  gastric  or 
duodenal  ulcer,  but  with  care  may  in  most  cases  be  diagnosed  from 
them.  The  chief  complaint  is  of  pain  situated  in  the  epigastrium, 
occurring  in  attacks,  often  due  to  exercise.  Between  the  attacks 
there  is  often  a  continual  gastric  discomfort.  The  pain  may  come 
on  shortly  after  food,  or  be  delayed,  and,  as  pointed  out  by  Paterson, 
often  radiates  to  the  right  iliac  fossa.  Vomiting  is  rarely  present, 
but  nausea  is  frequent. 

During  an  attack,  slight  rigidity  and  deep  tenderness  may  be 
present  in  the  right  iliac  fossa,  and  the  temperature  is  a  little  raised. 
Between  the  attacks,  tenderness  may  be  absent.  Hsematemesis  may 
occur. 

The  symptoms  have  been  attributed  by  W.  J.  Mayo  and  by 
Moynihan  to  pyloric  spasm,  by  Soltau  Fenwick  and  Paterson  to 
hypersecretion  of  gastric  juice.  I  believe  the  former  to  be  the  ex- 
planation in  most  cases  of  this  nature.  In  a  large  number  of  the 
cases  of  "  appendix  dyspepsia "  that  have  come  under  my  care, 
free  HC1  has  been  absent  and  the  total  acidity  low.  It  must  be 
remembered,  however,  that  disease  of  the  appendix  may  give  rise 
to  "  erosions  "  of  the  mucous  membrane  of  the  stomach,  which  may 
go   on  to  chronic  ulceration. 

Careful  attention  to  the  history,  confinement  to  bed,  and  examina- 
tion during  the  attack  should  in  most  cases  enable  the  surgeon  to  make 
the  diagnosis. 

Carcinoma. — The  differential  diagnosis  between  carcinoma  and 
non-malignant  gastric  ulcer  is  discussed  elsewhere  (p.v*86).  It 
must  first  be  remembered  that  in  not  a  few  cases  carcinoma  is 
directly  implanted  on  chronic  ulcer,  and  that  in  these  cases  there 
may  be  no  symptoms  or  signs  that  the  ulcer  has  become  malignant  ; 
the  usual  history  of  chronic  ulcer,  extending  over  years,  is  obtained, 
with  remissions  of  almost  complete  health,  and  the  diagnosis  of  malig- 
nancy is  only  made  at  operation.     The  history  of  primary  carcinoma 


35°  THE   STOMACH   AND    DUODENUM 

is  usually  insidious,  and  includes  the  onset  of  gastric  symptoms  at 
middle  age,  a  distaste  for  food,  a  gnawing  pain,  often  not  definitely 
relieved  when  the  stomach  is  empty,  and  a  steady  downward  progress. 
Vomiting  is  not  so  constant  as  in  ulcer,  and  may  be  of  tLe  "  coffee- 
grounds  "  type.  The  onset  of  symptoms  of  pyloric  stenosis  without 
previous  history  of  gastric  trouble  usually  means  carcinoma. 

Prognosis. — All  modern  observers  are  agreed  that  a  chronic 
gastric  ulcer  carries  with  it  a  grave  prognosis.  It  is  well  known  that 
relapse  after  medical  treatment  and  apparent  cure  is  common. 

The  following  figures  illustrate  the  mortality  and  the  chances  of  relapse 
under  medical  treatment.  Taking  hospital  cases  first,  Mansell-Moullin  has 
published  the  following  figures :  During  the  years  1897  to  August,  1902. 
500  patients  whose  cases  were  diagnosed  as  gastric  ulcer  were  admitted  into 
the  London  Hospital,  of  whom  402  were  women,  98  men.  Of  these  18  per 
cent,  died,  10  per  cent,  from  peritonitis,  2  per  cent,  from  haematemesis.  These 
figures  do  not  include  death  from  remote  complications  such  as  pyloric 
stenosis?,  hour-glass  stomach,  perigastric  adhesions,  etc.,  but  comprise  many 
case?,  particularly  in  women,  of  the  so-called  "  medical "  gastric  ulcer. 

The  figures  given  by  Habershon  express  more  nearly  the  prognosis.  Of 
60  cases  of  chronic  gastric  ulcer  in  preoperative  days  24  died,  11  of  perfora- 
tion. 7  of  haemorrhage,  and  6  of  exhaustion. 

With  regard  to  the  liability  to  relapse  in  those  cases  treated  medically,  in 
Mansell-Moullin' s  statistics  42  per  cent,  had  suffered  before  and  been  relieved  by 
treatment.  Greenhough  and  Joslin  published  the  following  results  of  medical 
treatment :  Of  187  cases  the  initial  mortality  was  8  per  cent.  ;  after  five 
years,  115  patients  could  be  traced,  and  of  these  57  had  had  recurrence  and 
15  had  died  of  gastric  diseases.  Paterson  and  Rhodes  investigated  the 
after-history  of  147  patients  who  had  been  in  the  London  Temperance 
Hospital  under  the  care  of  Soltau  Fenwick  and  Parkinson  ;  of  these  72 
could  be  traced,  and  46  of  them  were  not  cured. 

The  results  of  the  surgical  treatment  of  chronic  gastric  ulcer  and  its 
complications  are  now  becoming  well  known,  and  the  operative  mortality 
is  falling.  The  following  figures  are  instructive :  Moynihan  operated  upon 
334  cases  with  21  deaths — 6  per  cent.  ;  Mayo  Robson  (excluding  perforation) 
operated  upon  400  cases  with  12  deaths — 3  per  cent.  ;  and  Mayo,  307,  with 
a  death-rate  of  6"2  per  cent. 

We  may  conclude  that  the  immediate  mortality  of  the  surgical  treatment 
of  chronic  gastric  ulcer,  including  perforation,  is  less  than  the  immediate 
mortality  of  medical  treatment ;    excluding  perforation  it  is  much  less. 

The  final  results  are  infinitely  better.  Large  numbers  of  patients  have 
now  been  traced  after  operation  up  to  17-18  years.  Mayo  Robson,  Moj'nihan 
and  Paterson  (collected  cases),  Mayo,  Rutherford  Morrison,  Busch,  and  others 
have  published  series  of  cases  of  definite  chronic  ulcers  demonstrated  at 
operation  in  which  the  patient  was  well  when  seen  more  than  two  years 
after  the  operation.  Of  these  80-90  per  cent,  were  cured,  another  5-10 
per  cent,  were  relieved,  and  the  failures  were  less  than  10  per  cent. 

Treatment. — The  treatment  of  gastric  ulcer  is  at  first  medical. 
Surgical  treatment  must  not  be  considered,  except  in  the  case  of  per- 
foration or  certain  cases  of  haematemesis,  until  all  carious  teeth  have 


GASTRIC    ULCER:    TREATMEN1  351 

been  attended  to  and  the  patienl  has  been  kepi  at  rest,  in  bed  and 
subjected  to  medical  treatment.  If  this  fails  to  relieve,  01  relapse 
occurs,  surgical  treatment  should  l>e  adopted  as  offering  the  patient 
almost  certain  relief  with  the  prospect  of  cure  in  over  80  per  cent. 
of  ruses  at    a    very  Blight   risk-. 

There  is  still  some  difference  of  opinion  with  regard  to  the  actual 
surgical  treatment  of  gastric  ulcer.  Two  operations  are  performed 
— the  direct,  excision;  the  indirect,  gastrojejunostomy — by  which  the 
condition  of  t  he  stomach  is  influenced  so  as  to  allow  the  ulcer  to  heal. 

Most  surgeons  are  agreed  that  gastrojejunostomy  is  the  operation 
of  choice  in  cases  in  which  the  ulcer  is  in  the  pyloric  region  of  the 
stomach,  but  opinions  are  divided  as  to  the  treatment  of  ulcers 
situated  on  the  lesser  curvature,  away  from  the  pylorus.  Moynihan 
and  Mayo  consider  that  ulcers  in  this  situation  should  be  treated 
directly  by  excision,  as  in  their  experience  the  results  of  treatment 
by  gastroenterostomy  in  such  cases  are  not  so  good  as  in  ulcers  else- 
where. Rodman,  however,  on  the  grounds  that  carcinoma  starts 
from  chronic  ulcer,  and  that  ha?morrhage  and  perforation  have  followed 
g  i-tro-jejunostomy  successfully  performed,  advocates,  even  in  pyloric 
ulcers,  excision  of  the  pylorus  and  lesser  curvature  with  posterior 
gastrojejunostomy,  practically  a  partial  gastrectomy.  But  it  has 
to  be  proved  that  carcinoma  develops  in  the  scar  of  a  healed  ulcer, 
although  Moynihan's  cases  are  suggestive  (see  p.  352).  Even  after 
resection  of  the  ulcer,  relapse  has  occurred  ;  Mansell-Moullin,  Robson, 
Sinclair  White,  Terrier,  Deaver,  and  others  have  recorded  such  cases. 
Ulcers  are  also  frequently  multiple. 

That  an  ulcer,  although  causing  no  obstruction,  heals  after  gastro- 
jejunostomy is  now  established.  I  recorded  a  case  in  which  the  patient 
died  of  a  cause  other  than"  gastric,  twenty-eight  months  after  I  had 
performed  gastrojejunostomy  for  a  large  saddle-shaped  ulcer  on  the 
lesser  curvature,  adherent  to  the  pancreas.  It  had  quite  healed,  and 
the  scar  was  hardly  visible.  Sir  Frederic  Eve  has  recorded  a  case  in 
which  the  ulcer  was  healed  five  weeks  later.  Similar  cases  have  been 
described  by  others. 

With  regard  to  the  after-effects,  it  has  been  urged  that  excision 
should  be  performed  because  perforation  and  haemorrhage  may  occur 
before  the  ulcer  is  healed,  or  carcinoma  may  develop  later.  Isolated 
cases  of  perforation  following  gastrojejunostomy  for  gastric  ulcer 
have  been  published.  More  cases  of  hsematernesis  have  been  recorded, 
and  fatal  cases  have  been  reported  by  Robson,  Kocher,  Mayo,  etc., 
at  periods  when  the  patient  was  apparently  well.  In  one  patient 
who  was  under  my  care,  one  month  after  gastrojejunostomy  a  sudden 
and  fatal  haemorrhage  occurred  from  an  artery  in  the  floor  of  a  large 
ulcer  adherent  to  the  pancreas  and  spreading  to  the  lesser  curvature 


35^      THE  STOMACH  AND  DUODENUM 

and  anterior  surface.  It  had  originally  been  saddle-shaped,  but  its 
anterior  part  had  healed  after  operation.  As  to  malignant  disease, 
cases  have  been  recorded  by  Kobson,  Moynihan,  Czerny,  Deaver,  and 
others  in  which  a  malignant  tumour  developed  as  long  as  three 
years  and  a  half  after  gastrojejunostomy  had  been  performed.  In 
two  of  my  own  cases — one  of  adherent  ulcer  on  the  lesser  curvature, 
and  the  other  of  pyloric  ulcer — malignant  disease  declared  itself 
within  twelve  months.  The  first  could  not  have  been  excised,  the 
second  could.  Both  these  cases  were  instances  of  errors  in  diag- 
nosis ;  the  difficulties  in  distinguishing  between  the  two  conditions 
are  notorious,  and  it  is  likely  that  in  some  of  the  recorded  cases 
similar  mistakes  occurred.  Perforation  and  haemorrhage  can  be 
avoided  by  infolding  the  ulcer  where  possible,  but  the  onset  of  malig- 
nant disease  cannot  be  prevented.  Against  this  are  the  records 
of  many  cases  in  which  tumours  thought  to  be  malignant  and  irre- 
movable at  operation  disappeared  after  gastrojejunostomy.  In  one 
case  under  my  care  no  tumour  could  be  felt  fourteen  days  later. 

At  the  present  time  it  may  be  said  that  gastro-jejun ostomy  is 
the  operation  of  choice  for  chronic  gastric  ulcer,  but  it  should  be 
combined  with  infolding  where  possible,  and,  if  there  is  any  doubt 
as  to  malignancy,  with  excision  of  the  ulcer  or  partial  gastrectomy. 
The  abdomen  should  be  opened  by  an  incision  over  the  right  rectus 
muscle  dividing  its  anterior  sheath.  The  muscle  should  then  be  pulled 
outwards  and  its  posterior  sheath  and  the  peritoneum  divided.  After 
protecting  the  edges  of  the  wound  with  gauze,  the  whole  stomach  and 
duodenum  should  be  carefully  examined  in  order  to  avoid  such  a 
catastrophe  as  performing  gastrojejunostomy  to  the  pyloric  pouch 
of  an  hour-glass  stomach,  an  operation  that  has  been  invariably  fatal. 
If  no  lesion  is  found  on  careful  examination  of  both  surfaces  of  the 
stomach,  the  posterior  being  inspected  through  an  opening  made  in 
the  transverse  meso-colon,  the  cause  of  the  trouble  should  be  sought 
elsewhere — in  the  gall-bladder  or  appendix.  Even  when  a  lesion 
is  found  in  the  stomach  these  organs  should  always,  if  the 
patient's  condition  will  permit,  be  examined,  and  any  disease  should 
be  dealt  with.  The.  stomach  should  not  be  opened  ;  if  the  lesion 
cannot  be  discovered  by  external  examination  it  is  not  a  chronic- 
ulcer,  and  is  unsuitable  for  surgical  treatment.  It  cannot  be  too 
often  insisted  upon  that  gastrojejunostomy  must  never  be  per- 
formed unless  a  definite  lesion  is  present  in  the  stomach  ;  it  must 
never  be  done  for  symptoms.  A  chronic  ulcer  will  show  definite 
signs  of  its  presence  on  inspection  or  palpation.  On  inspection 
a  rough,  red-stippled  area  is  usually  seen,  often  somewhat  puckered. 
If  the  ulcer  be  on  the  lesser  curvature,  an  enlarged  lymphatic  gland 
is  frequently  present.     In  the  diagnosis  from  carcinoma  due  weight 


GASTRIC    ULCER  353 

must  be  placed  on  the  history  and  on  the  chemical  examination  ol 
the  stomach  contents.  It'  the  ulcer  be  malignant,  induration  is  mop 
marked,  the  peritoneum  is  often  thickened  and  does  not  show  the 
same  rough  red  appearance,  the  lymphatic  glands  are  enlarged  and 

hard,  and  thickened  lymphatics  are  frequently  seen  running  from   the 

growl  h  to  the  glands. 

The  preferable  operation  is  posterior  gastrojejunostomy  [see  p.  406), 
the  opening  in  the  stomach  being  vertical.  When  possible  the  ulcer 
should  be  excised  or  infolded  in  addition.  If  gastric  adhesions 
render  the  posterior  operation  impossible,  the  anterior  nodoop  gastro- 
enterostomy should  be  done  (see  p.  408). 

If  there  is  any  suspicion  that  the  ulcer  is  malignant,  a  portion 
of  its  edge  or  an  enlarged  gland  should  be  removed  for  rapid 
microscopical  examination ;  a  gastrojejunostomy  suitable  for  use 
after  partial  gastrectomy  should  be  performed,  and  the  latter 
operation  completed  on  receiving  the  pathologist's  report. 

After-treatment. — As  soon  as  the  patient  has  recovered  from 
the  anaesthetic  he  should  be  propped  up  in  bed  and  remain  in 
a  sitting  position.  When  any  anaesthetic  vomiting  has  ceased, 
feeding  may  be  commenced.  I  am  in  the  habit  of  ordering  Benger's 
or  Allenburys'  food  in  preference  to  milk,  but  any  form  of  bland 
diet  may  be  given.  Food  should  be  increased  cautiously ;  many 
patients  develop  a  ravenous  appetite,  but  they  should  be  cautioned 
against  over-eating.  It  is  wise  to  put  the  patient  on  alkalis  ;  a  powder 
composed  of  equal  parts  of  bismuth  oxycarbonate,  heavy  magnesium 
carbonate,  and  sodium  bicarbonate,  in  doses  of  3*  three  times  a  day, 
is  useful. 

It  must  be  remembered  that  prolonged  supervision  is  necessary 
after  operation,  which,  though  the  most  important,  is  only  the  first 
step  in  the  treatment. 

Perforation  of  Gastric  Ulcer 
Among  the  complications  of  gastric  ulcer,  perforation  is  the  most 
serious,  fully  95  per  cent,  of  the  cases  thus  complicated  terminating 
fatally  unless  treated  by  operation.  Various  figures  have  been  given 
stating  the  percentage  of  cases  in  which  perforation  occurs,  but  all 
such  figures,  based  as  they  are  upon  a  diagnosis  of  gastric  ulcer 
made  from  symptoms,  are  useless. 

The  ulcer  which  perforates  may  be  an  acute  one  of  a  few  hours'  or  days' 
duration,  or  a  chrome  one  which  has  been  in  existence  for  many  years.  In 
many  cases  gastric  symptoms  suggestive  of  ulceration  have  been  present 
for  a  considerable  time.  Thus,  of  28  cases  which  have  been  under  my  care, 
in  16  symptoms  had  been  present  over  two  years,  in  2  ten  years,  and  in  1 
thirteen  years.  In  1  case  only  were  the  symptoms  of  less  than  two  months' 
duration  (a  week). 


554  THE   STOMACH   AND   DUODENUM 

Perforation  of  a  gastric  ulcer  occurs  most  often  in  young  women  ;  thus, 
of  132  cases  treated  at  the  London  Hospital  in  ten  years  (1899-1908),  92  were 
women,  of  whom  55  were  between  the  ages  of  15  and  25.  The  age-incidence 
in  men  is  higher  ,  in  the  40  males,  only  6  occurred  in  this  decennium,  14 
between  25  and  35,  13  between  35  and  45.  No  satisfactory  explanation  can 
be  given  of  this  difference,  for  of  the  107  cases  of  chronic  gastric  ulcer  in 
women  treated  surgically  during  the  same  tune  only  12  occurred  in  this 
decennium,  43  between  25  and  35.  and  27  between  35  and  45.  corresponding 
well  to  the  ages  at  which  chronic  ulcers  are  met  with  in  men,  viz.  among  100. 
24  between  25  and  35,  42  between  35  and  45. 

Ulcers  which  perforate  are  usually  situated  on  the  anterior  wall  of  the 
stomach,  nearer  the  lesser  than  the  greater  curvature,  and  the  pylorus  than 
the  cardia  ;  no  facts  have  been  adduced  to  explain  why  ulcers  in  this  situation 
are  more  common  in  young  women.  Among  the  28  cases  operated  upon 
by  myself  the  perforation  was  on  the  anterior  wall  in  25,  but  in  several  the 
ulcer  was  on  the  lesser  curvature  and  saddle- shaped.  Perforations  may  be 
multiple  ;  Deaver  and  Ashurst  state  that  in  about  20  per  cent,  of  cases  two 
or  more  perforations  have  been  found  ;  but  among  my  own  cases  there  was 
1  only  in  which  two  ulcers  had  perforated. 

The  immediate  cause  of  the  perforation  is  the  separation  of  a 
slough  or  spread  of  the  ulceration,  but  it  may  occur  from  over-distension 
of  the  stomach,  or  as  the  result  of  a  sudden  strain.  As  pointed  out 
by  Brinton,  it  is  "  often  directly  traceable  to  mechanical  violence, 
such  as  coughing,  sneezing,  convulsion  or  constriction  of  the  belly." 
Alexander  Miles  found  that  of  30  cases  of  perforated  gastric  ulcer 
treated  by  him,  in  15  the  perforation  occurred  while  the  patient  was 
at  rest ;  only  6  were  engaged  in  such  a  way  as  to  involve  muscular 
strain. 

The  perforation  may  be  acute,  subacute,  or  chronic  (the  first  is 
the  more  common  ;  among  my  cases  2  were  chronic  and  3  subacute) ; 
it  is  usually  rounded  ;  it  varies  in  size,  but  as  a  rule  is  not  larger 
in  diameter  than  a  small  pea. 

The  perforation  is  acute  when  the  giving  way  of  the  ulcer  allows 
the  contents  of  the  stomach  to  obtain  access  to  the  general  peritoneal 
cavity.  In  a  subacute  perforation  the  stomach  is  empty,  or  extravasa- 
tion is  limited  by  adhesions  to  the  abdominal  wall,  the  under  surface 
of  the  liver,  or  the  omentum.  In  this  type  of  case  recovery  without 
operation  may  take  place  if  the  patient  be  kept  at  rest  and  starved. 
A  chronic  perforation  most  often  occurs  when  the  ulcer  is  on  the  pos- 
terior wall.  There  may  be  no  sudden  onset  of  additional  symptoms, 
and  the  diagnosis  may  be  impossible  until  a  subphrenic  or  a  perigastric 
abscess  forms. 

Symptoms. — It  has  been  stated  that  perforation  may  be  the 
first  sign  of  the  presence  of  a  gastric  ulcer.  In  my  experience  this  is 
unusual ;  in  all  the  cases  under  my  care  symptoms  had  been  present, 
in  most  for  a  considerable  time,  in  one  for  a  week  only  ;  in  a  few 
the  symptoms  have  increased  in  severity  for  a  short  time  preceding 


GASTRIC    ULCER:     PERFORATION  355 

perforation.     This  is  also  the  experience  of   Moynihan,  who  state 
"The  perforation  of  an  ulcer  oi  the  stomach  is  a  catastrophe  which, 
in  my  experience,  never  comes  unannoum  ed. 

The  pai icnt  is  suddenly  Beized  with  agonizing  pain  in  the 
epigastric  region;  in  some  cases  the  pain  shoots  to  the  left 
Bhoulder.  II  seen  short Iv  alter  perforation,  shock-  is,  as  a  rule, 
absent,  and  the  pulse-rate  is  not  increased;  this  should  be  borne 
in  mind.  Board  like  rigidity  and  deep  tenderness  appear  early, 
both  Bigns  being  lirst  present  and  most  marked  iii  the  epigastric 
region.  In  a  few  cases  this  early  rigidity  may  be  absent,  but 
tenderness  is  always  present.  Gradually  the  pulse-rate  rises,  collapse 
sets  in.  and  1  he  abdomen  becomes  distended,  indicating  that  the 
most  favourable  time  for  operation  has  passed.  The  initial  severe 
pain  passes  oil'  usually  in  less  than  an  hour. 

Vomiting  occurs  shortly  alter  the  onset  of  the  pain  in  about  half 
the  cases,  but  is  usually  not  repeated,  and  is  not  frequent  until  peri- 
tonitis lias  developed.  In  many  cases  the  temperature  is  subnormal 
directly  after  the  perforation.  Liver-dullness  may  be  absent  if  much 
gas  has  escaped  into  the  peritoneal  cavity,  but  it  is  not  a  sign  on 
which  reliance  can  be  placed.  General  subcutaneous  emphysema 
has  been  noticed  as  a  rare  complication. 

Cases  have  been  recorded  in  which  death  occurred  from  the  severe 
pain  or  shock  of  perforation.  In  a  case  which  recently  came  under 
my  notice,  death  took  place  two  hours  after  perforation  of  an  acute 
ulcer,  in  a  girl  of  19. 

In  subacute  perforation  there  are  often  for  several  days  premonitory 
symptoms  of  stabbing  pain,  or  a  feeling  of  aching  or  stiffness,  but  at 
the  time  of  perforation  the  symptoms  are  less  acute.  Unless  operated 
on,  the  condition  usually  leads  to  the  formation  of  a  perigastric  abscess 
{see  p.  373). 

Diagnosis. — No  difficulty  arises  in  the  majority  of  cases.  The 
sudden  onset  of  acute  abdominal  pain  in  a  young  woman  who  has  had 
gastric  symptoms  previously  should  lead  to  the  correct  diagnosis. 
In  men  it  is  often  difficult  to  decide  before  operation  whether  the  ulcer 
is  gastric  or  duodenal,  but  this  is  a  matter  of  no  importance.  But 
cases  occur  in  which  no  previous  history  of  gastric  trouble  can  be 
obtained.  In  many  catastrophes  in  the  upper  abdomen  no  definite 
diagnosis  can  be  made,  but  these  are  cases  in  which  the  correct  treat- 
ment is  operative — e.g.  perforation  of  the  gall-bladder,  or  acute  pan- 
creatitis. 

Acute  appendicitis  may  be  simulated  by  a  subacute  perforation 
of  the  stomach,  but  with  much  less  frequency  than  by  perforation  of 
duodenal  ulcers. 

Ruptured  tubal  pregnancy  should  also  give  rise  to  no  difficulty 


356  THE    STOMACH    AND    DUODENUM 

in  diagnosis  if  attention  be  paid  to  the  history,  the  onset  of  the 
symptoms,  and  the  appearance  of  the  patient. 

In  acute  intestinal  obstruction  there  is  the  same  sudden  onset 
of  agonizing  pain,  but  vomiting  is  a  constant  feature  and  the  localiza- 
tion of  the  pain  is  different. 

Acute  dilatation  of  the  stomach  and  gastric  volvulus  should  not 
be  confused  with  perforation  of  the  viscus. 

Rare  conditions  that  have  misled  are  mesenteric  thrombosis, 
ptomaine  poisoning,  abdominal  crises  in  diabetes  (Downes  and  O'Brien), 
gastric  crises  of  tabes,  and  haemorrhage  into  the  ovary  at  about  the 
time  of  menstruation  (Waring). 

Cases  have  occurred  in  which  there  has  been  a  sudden  onset  of 
severe  abdominal  pain  accompanied  by  rigidity  in  patients  the  subjects 
of  gastric  ulcer,  in  whom  at  operation  no  perforation  was  discovered, 
and  other  cases  in  which  no  cause  was  found  for  the  symptoms.  The 
phenomenon  was  called  "  pseudo-perforation  "  by  Manges,  who  recorded 
a  case  of  this  nature. 

Very  rarely,  as  in  the  case  recorded  by  Moore,  another  lesion  is 
present ;  in  this  case  perforated  gastric  ulcer  was  complicated  by 
acute  appendicitis. 

Prognosis.— Death  is  inevitable  in  over  95  per  cent,  of  the 
cases  not  treated  by  operation.  The  prognosis  depends  upon  the 
time  after  perforation  at  which  operation  can  be  performed  ;  if 
the  patient  is  seen  within  the  first  twenty-four  hours  the  death-rate 
should  be  not  more  than  10  per  cent. 

Sinclair  Kirk  has  recorded  11  cases  in  which  he  operated,  with  recover y 
in  all.  In  8  cases  the  operation  was  done  within  5  hours  of  perforation, 
in  1  at  7,  in  1  at  10,  and  in  1  at  20  hours. 

The  death-rate  at  the  present  time  in  large  numbers  of  cases  is  about 
50  per  cent.  Thus,  Gross  and  Gross  collected  the  reports  of  369  operations 
with  a  death-rate  of  nearly  51  per  cent.  The  death-rate  at  St.  Thomas's 
Hospital  (Sargent)  for  the  fifteen  years  up  to  1904  was  55  per  cent.,  at 
St.  Bartholomew's  between  1897  and  1905,  49  per  cent.  (69  cases).  During 
the  years  1899-1908  there  were  132  cases  of  perforated  gastric  ulcers  operated 
upon  at  the  London  Hospital,  with  a  death-rate  of  67  per  cent. ;  but  of 
this  number  less  than  5  were  within  12  hours  of  perforation. 

During  the  last  nine  years  I  have  operated  upon  28  cases,  with  16  re- 
coveries ;  of  these  10  were  seen  within  24  hours  of  perforation — at  4  (2  cases), 
6,  9,  10,  11,  12  (2  cases),  18,  22  hours — and  recovery  took  place  in  all  ;  the 
remainder  were  over  this  period — from  26  hours  to  3  weeks. 

Treatment. — Abdominal  section  should  be  performed  at  once  ; 
no  time  should  be  wasted  in  waiting  for  "  shock  "  to  pass  off,  for  this 
will  be  best  relieved  by  immediate  operation.  It  must  be  remembered 
that  if  the  case  is  seen  early  there  may  be  no  shock. 

The  abdomen  should  be  opened  in  the  middle  line.  In  many 
cases,  as  soon  as  the  peritoneum  is  reached  it  is  seen  to  be  blown  out 


GASTRIC    ULCER:     PERFORATION  357 

in  a  bladder-like  way  by  the  aii  contained  in  the  peritonea]  cavity. 

The  stomach  should  be  quickly  found.    As  a  rule  the  perforation  if 

easily  discovered,  as  it  is  usually  on  the  anterior  wall.  Unless  the 
case  he  veiv  recent,  it  will  generally  he  surrounded,  by  yellow  lymph. 
It'  the  ulcer  is  not  seen  on  the  anterior  surface  or  in  the  duodenum, 
a  wide  opening  should  be  made  in  the  gastro-colic  omentum  and  the 
posterior  surface  examined.  If  no  ulcer  is  present,  the  gall-bladder 
and  pancreas  must  be  examined,  and  then  the  appendix  and  pelvic 
organs.  The  perforation  should  be  infolded,  chromic  gut  being  used, 
and  the  area  buried  by  a  continuous  stitch  of  silk.  It  is  sometu 
impossible  to  close  the  perforation  in  this  way  on  account  of  the 
friability  of  the  tissues  immediately  around  the  ulcer  or  the  amount 
of  induration  present ;  in  these  cases  the  ulcer  should  be  rapidly 
excised,  or,  if  the  condition  of  the  patient  will  not  permit,  a  piece  of 
omentum  may  be  brought  up  and  stitched  over  the  ulcer,  or,  if  this 
is  impossible,  the  perforation  should  be  covered  by  iodoform  gauze 
packing. 

As  perforation  of  two  ulcers  has  occurred  simultaneously  in  many 
recorded  cases,  search  should  always  be  made  for  other  lesions. 

Gastrojejunostomy  should  be  performed  at  the  same  time  in  all 
cases  in  winch  closure  of  the  perforation  produces  pyloric  contraction 
or  any  deformity  of  the  stomach  likely  to  interfere  with  its  action, 
when  more  than  one  ulcer  is  present,  or  when  the  ulcer  that  has 
perforated  is  a  chronic  one.  It  is  unnecessary  in  perforation  of  an 
acute  ulcer  on  the  anterior  wall.  The  performance  of  this  operation 
at  the  time  of  closure  of  the  perforation  will  lead  to  a  more  rapid 
convalescence  and  the  prevention  of  after-trouble. 

Various  opinions  have  been  held  with  regard  to  the  need  for  this  step. 
\Y.  J.  Mayo  found  that  only  one  out  of  18  patients  needed  gastrojejunostomy 
later,  and  Hale  White  states  :  "  Judging  from  the  results  at  Guy's  Hospital, 
it  appears  that  patients  who  survive  an  operation  for  perforated  gastric 
ulcer  do  so  well  that  gastroenterostomy  is  unnecessary."  But  this  has 
not  been  the  experience  of  most  observers.  Paterson  found  23  per  cent, 
of  patients  relapse  within  a  year  of  operation.  Of  the  16  patients  upon 
whom  I  operated  and  who  recovered,  I  performed  gastrojejunostomy  at 
the  time  in  6,  and  excised  the  ulcer  in  1 ,  gastrojejunostomy  was  necessary 
at  a  later  date  in  4. 

After  the  perforation  has  been  closed  and  gastrojejunostomy 
performed,  if  this  has  been  considered  necessary,  all  extravasation 
should  be  gently  wiped  away  and  the  abdomen  closed  without  drainage, 
unless  the  extravasation  has  been  considerable,  when  a  tube,  brought 
out  on  the  loin,  should  be  placed  in  the  right  or  left  kidney  pouch 
according  to  whether  the  extravasation  has  been  from  an  ulcer  at  the 
pyloric  or  the  cardiac  end.  If  the  peritoneal  soiling  has  been  general, 
it  will  be  well  to  drain  supra pubically  also. 


358  THE    STOMACH   AND    DUODENUM 

After-treatment. — After  operation  the  patient  should  be  nursed 
in  the  propped-up  position  and,  as  soon  as  postan aesthetic  vomiting  lias 
passed  off,  should  be  given  small  quantities  of  water.  It  is  unnecessary 
to  institute  rectal  feeding,  for  within  thirty-six  hours  of  operation  the 
patient  should  be  taking  Benger's  food,  or  albumin-water  and  glucose. 

Careful  attention  must  be  paid  to  the  mouth,  to  avoid  parotitis. 

As  soon  as  discharge  ceases  the  tube  should  be  removed. 

If  general  peritonitis  is  present,  nothing  should  be  given  by  the 
mouth  until  vomiting  has  ceased  and  the  condition  of  the  patient 
shows  that  feeding  is  safe.  Continuous  saline  infusion  is  given  per 
rectum.  After  from  twenty-four  to  thirty-six  hours,  if  the  condition 
of  the  patient  is  satisfactory,  water  may  be  given  by  the  mouth,  and 
a  start  made  on  albumin-water  and  glucose,  Benger's  food,  or  milk 
and  water,  but  if  this  causes  increase  in  pulse-rate  or  vomiting  it 
should  not  be  persisted  in.  On  no  account  should  aperients  be  given, 
and  the  resumption  of  food  should  be  gradual. 

A  continuing  temperature  with  gradual  loss  of  flesh  should  raise 
suspicion  that  a  subphrenic  abscess  is  present ;  this  should  be  sought 
(see  p.  374),  and  treated  in  the  usual  way. 

After  the  patient  is  free  from  danger,  all  carious  teeth  should  be 
removed  and  alkalis  given. 

Ultimate  prognosis. — If  the  ulcer  which  perforated  is  acute, 
situated  on  the  anterior  surface  of  the  stomach  and  capable  of  being 
infolded,  no  further  symptoms  will  develop  in  most  cases.  If,  on  the 
other  hand,  the  ulcer  is  a  chronic  one,  the  infolding  may  be  difficult 
and  part  of  the  ulcer  may  escape  ;  for  example,  if  a  saddle-shaped 
ulcer  on  the  lesser  curvature  perforates  on  its  anterior  wall,  this  part 
may  be  infolded  and  healed,  but  the  remainder  of  the  ulcer  is  un- 
affected, and,  unless  excision  or  a  simultaneous  gastrojejunostomy 
be  done,  symptoms  will  recur. 

Perigastritis — Gastric  Adhesions 

Adhesions  connecting  the  stomach  to  the  abdominal  wall  or  to 
other  viscera  are  commonly  due  to  gastric  or  duodenal  ulcers,  but 
may  be  due  to  diseases  of  other  abdominal  viscera,  most  commonly 
the  gall-bladder. 

Through  the  attachment  of  the  great  omentum  to  the  stomach, 
this  organ  may  be  interfered  with  in  disease  of  any  part  of  the  abdomen. 
In  one  patient  upon  whom  I  operated,  gastric  symptoms,  which  at 
one  time  had  been  thought  to  be  due  to  gastric  ulcer,  were  found  to  be 
caused  by  adhesions  of  the  great  omentum  to  the  uterus  at  the  site 
of  removal  of  the  left  Fallopian  tube. 

Adhesions  resulting  from  gastric  or  duodenal  ulcers  are  most  common 
to  the  pancreas  and  to  the  liver  ;  in  123  cases  recorded  by  Femvick  they 


G  \STKIC    ADHESIONS 

bound  the  Btomach  to  the  pancreas  in  49,  to  the  liver  in  33,  to  the  i 

in  7.  and  to  the  liver  and  colon  together  in  4. 

In  the  majority  of  cases,  adhesions,  whether  due  to  extrinsic  oi 
intrinsic  causes,  give  rise  to  no  Bymptoms  whatever.  In  the  pvlorii 
region,  aa  the  result  of  constriction  or  fixation  <>f  the  pylorus  at  a 
higher  level  than  normal,  dilatation  may  result  (see  p.  .327).  Adhesioi 
of  the  stomach  to  the  anterior  abdominal  wall  or  constriction  by 
adhesion  may  Lead  to  hour-glass  Btomach.  Jn  Buch  cases  aa  tl 
definite  symptoms  of  stenosis  will  be  present. 

It  is  in  the  cases  in  which  pain  is  the  prominent  feature  that 
difficulties  are  most  likely  to  occur.  Pain  arises  most  often  when 
the  adhesions  are  to  the  most  movable  portion  of  the  stomach,  tin- 
greater  curvature.  Hale  White,  speaking  of  this  subject,  saya  :  "  I 
am  not  sure,  but  I  think  they  most  often  give  rise  to  symptoms  when 
they  connect  the  stomach  with  the  bowel." 

The  pain  is  often  worse  after  food,  but  it  may  be  absent  for  days 
and  weeks,  and  in  some  cases  bears  no  relation  to  meals.  It  is  often 
worse  on  exertion,  and  the  patient  may  complain  that  the  pain  is 
increased  if  she  reaches  above  the  head  or  stands  quite  erect.  The 
long-continued  pain  may  set  up  neurasthenic  symptoms. 

There  may  be  distinct  deep  tenderness  with  muscular  rigidity 
over  the  area  occupied  by  the  adhesions. 

Diagnosis. — This  must  rest  on  the  history  of  previous  abdominal 
trouble  such  as  might  cause  a  local  peritonitis. 

Treatment. — If  the  adhesions  have  caused  hour-glass  stomach 
or  gastric  dilatation,  the  appropriate  treatment  for  these  conditions 
must  be  carried  out.  When  pain  is  the  chief  complaint  and  is  of 
sufficient  severity  to  interfere  with  the  patient's  work,  operation 
should  be  undertaken  for  the  purpose  of  separating  the  adhesions, 
care  being  exercised  to  avoid  overlooking  any  perforation  of  stomach 
which  may  have  been  closed  by  them.  The  adhesions  should  be 
cleanly  divided,  and  both  ends  ligatured.  If  a  large  raw  surface  is 
left,  the  edge  of  the  omentum  may  be  used  to  cover  it. 

Attempts  at  preventing  the  re-formation  of  adhesions  by  covering 
the  raw  surface  with  Cargile  membrane  or  by  leaving  saline  solution 
in  the  abdominal  cavity  have  not  been  very  successful. 

Symptoms  may  persist  after  the  division  of  adhesions,  particularly 
in  women  in  whom  neurasthenia  has  supervened. 

DUODENAL    ULCER 

Ulcers  resembling  those  occurring  in  the  stomach,  and  probably 
caused  in  a  similar  way  (see  p.  340),  are  frequently  found  in  the 
duodenum.     They  may  be  divided  into  the  acute  and  the  chronic. 

Etiology. — As  in  the  stomach,  the  acute  ulcers  may  be   found 


36o 


THE   STOMACH   AND   DUODENUM 


complicating  many  diseases,  especially  those  in  which  sepsis  is  present. 
There  is  a  close  association  between  chronic  appendicitis  and 
duodenal  ulcer ;  it  is  probable  that  the  appendix  is  the  source  of 
the  infection  in  many  cases. 

Burns. — Ulcers  occurring  in  the  duodenum  complicating  severe 
burns  were  described  by  Curling  in  1842  (Fig.  377)  ;  and  it  is  said 
they  may  also  be  present  in  the  stomach,  and  in  the  intestine 
lower  down.      Usually  single,   they   are   met  with  most  often  in  the 

first  portion  and  begin 
as  hsemorrhagic  ero- 
sions. They  are  said 
to  occur,  as  a  rule, 
from  seven  to  fourteen 
days  after  the  burn, 
but  they  may  be  dis- 
covered earlier — in  one 
case  (Parfick)  they  were 
seen  within  eighteen, 
hours.  These  ulcers 
often  lead  to  a  fatal 
issue  within  a  few  days 
from  haemorrhage  or 
perforation.  They  were 
more  frequently  met 
with  by  older  writers. 
Thus,  Fenwick,  from 
the  statistics  of  Holmes, 
Erichsen,  Perry  and 
Shaw,  found  this  com- 
plication in  6-2  per 
cent,  of  all  fatal  cases 
of  burns.  These  ulcers 
are  now  not  often  found 
after  burns,  and  some 
authors  deny  that  the 
two  conditions  are 
associated.  Various 
explanations  have  been 
given  of  the  development  of  these  acute  ulcers,  but  they  are  probably 
of  toxaemic  origin,  and  can  thus  be  brought  into  line  with  other 
acute  peptic  ulcers  (p.  342). 

Age. — Duodenal  ulcers  may  be  met  with  at  any  age.  Cases  have  been 
recorded  of  the  perforation  of  a  duodenal  ulcer  in  an  infant  of  21  hours,  and 
of  death  from  haemorrhage  from  a  duodenal  ulcer  in  an  infant  2  days  old. 


Fig.  377. — Duodenal  ulcer  following  burns, 
from  a  girl  7  years  of  age,  in  whom 
death  took  place  eight  days  later  from 
haemorrhage  from  the  pancreatico- 
duodenal artery.     ( Curling's  case. ) 

{Royal  College  of  Surgeons  Museum. ) 


DUODENAL    ULCER :     ETIOLOGY 


361 


Among  -7.'!  cases  collected  by  Collin,  1(>  were  under  a  year.  J11  these  the 
ulcers  were  acute,  usually  complicating  some  septic  disease  and  found  post 
mortem. 

Duodenal  ulcer  as  seen  clinically,  the  chronic  ulcer,  is  a  disease  of  adult 
life,  the  patient  most  often  coming  under  surgical  observation  between  thi 
ages  of  30  and  50.  In  many,  however,  symptoms  were  noticed  much  earlier 
in  life  :  for  instance,  in  one  patient  of  53  upon  whom  I  operated,  symptoms 
had  been  present  for  thirty-five  years,  and  in  another  of  <>8  for  forty-eight. 

Sex. — All  are  agreed  that  men  are  more  often  affected  than  women. 


Fig.  378. — Chronic  ulcer,  situated  on  the  posterior  wall  of  the  first 
part  of  the  duodenum,  which  had  eroded  the  pancreatico- 
duodenal artery.  A  bristle  is  in  the  artery ;  the  body  of 
the  pancreas  has  been  displaced  downwards. 

(London  Hospital  Pathological  Institute.) 

Of  Mayo  Robson's  cases  86  per  cent,  were  males,  of  the  Mayos'  73  per 
cent.,  and  of  Moynihan's  73*6  per  cent.  Among  my  own  cases  operated  up 
to  December,  1911,  70  in  number,  10  were  in  women.  This  may  be  con- 
nected with  the  greater  frequency  of  diseases  of  the  appendix  in  men.  Mayo 
has  observed  that  the  first  portion  of  the  duodenum  in  men  is  nearly  always 
ascending,  and  suggests  that  the  alkaline  reaction  of  the  bile  and  pancreatic 
juice  more  readily  neutralizes  the  acid  chyme  in  the  upper  duodenum  in 
women  than  in  men. 


362 


THE   STOMACH  AND   DUODENUM 


Situation. — Ulcers  occur  most  often  in  the  supra-anipullary  portion  of 
the  duodenum,  over  95  per  cent,  being  found  within  an  inch  of  the  pylorus. 
The  ulcer  is  usually  solitary,  and  situated  on  the  upper  and  anterior  Avail  ; 
next  in  order  of  frequency,  on  the  posterior  wall.  An  ulcer  in  this  latter 
situation  is  particularly  liable  to  be  associated  with  hsemorrhage,  which 
may  prove  rapidly  fatal  from  erosion  of  the  pancreatico-duodenal  artery 


Fig.  379. — Chronic  ulcer  on  the  posterior  wall,  with  acute 
perforated  ulcer  on  the  anterior  surface.  Duodenum 
opened  from  below. 

,  U.ondon  Hospital  Pathological  Institute.) 

(Fig.  378).     Occasionally  two  ulcers  are  present  on  opposite  sides  of  the 
intestine— contact  ulcers  (see  Fig.  379). 

The  morbid  anatomy  of  duodenal  ulcer  resembles  that  of  gastric 
ulcer,  with  which  it  may  coexist. 

Symptoms. — A  chronic  duodenal  ulcer  may  be  latent  until 
perforation  occurs.  In  the  majority  of  patients,  however,  it  gives 
rise  to  a  definite  train  of  symptoms.  In  a  few  cases  it  cannot  be 
distinguished  from  a  gastric  ulcer,  and  in  still  fewer  the  diagnosis 
of  peptic  ulcer  is  not  made  at  all. 


DUODENAL    ULCER:    SYMPTOMS  363 

Thus  we  may  conveniently  make  Eour  groups: — 
1.  Those  with  typical  symptoms. 
•J.  Those  with  symptoms  indistinguishable  from  gastrii    ulcer. 

3.  Those  in  which  diagnosis  is  impossible. 

4.  Those  presenting  no  symptoms  till  perforation. 

The  onset  of  the  disease  is  usually  insidious  ;  at  firsl  there  is  only 
1  sense  of  uneasiness,  or  a  feeling  of  distension.  Pain  is  rarely  absent, 
and  is  the  most  important  symptom;  it  appears  about  two  hours 
after  food,  and  lasts  until  the  next  meal,  by  which  it  is  relieved— hence 
the  name  '"  hunger-pain/'  applied  to  it  by  Movnihan.  A  characterise 
feature  of  the  pain  is  that  in  many  cases  it  wakens  the  patient  aboul 
1  or  2  a.m.  It  is  epigastric  and  may  pass  round  to  the  right  side,  i- 
often  relieved  by  pressure,  and  may  be  accompanied  by  eructation  of 
gas  or  regurgitation  of  a  little  bitter  fluid,  followed  by  relief.  Occasion- 
ally it  is  spasmodic,  doubling  the  patient  up  and  resembling  biliary 
colic.  It  is  sometimes  noted  that  the  period  of  relief  from  the  pain 
is  greater  after  the  ingestion  of  solid  than  of  liquid  food.  The  appetite 
often  remains  good  ;  indeed,  it  may  be  better  during  the  attack  than 
at  other  times. 

An  important  feature  is  the  complete  remission  of  symptoms, 
an  attack  lasting  a  few  weeks  being  followed  by  a  period  of  perfect 
health  which  may  last  for  months.  An  attack  is  particularly  prone  to 
come  on  in  the  winter,  and  may  result  from  cold,  worry,  or  overwork. 
Spontaneous  vomiting  is  very  unusual  unless  stenosis  occurs;  but 
self-induced  vomiting,  rare  in  gastric  ulcer,  is  noted  in  many  cases 
of  duodenal  ulcer. 

During  the  attack,  rigidity  of  the  upper  segment  of  the  right  rectus 
muscle  and  deep  tenderness  may  be  present,  but  in  many  cases 
abdominal  examination  is  negative. 

Symptoms  such  as  those  described  above  are  present  in  most  cases 
in  which  an  ulcer  is  situated  in  the  first  part  of  the  duodenum. 

It  must  be  remembered,  however,  that  the  presence  of  post- 
prandial or  nocturnal  pain,  relieved  by  a  warm  drink  or  by  bicar- 
bonate of  soda,  does  not  justify  a  certain  diagnosis  of  duodenal  ulcer  ; 
occasionally,  when  the  ulcer  is  situated  on  the  lesser  curvature  of 
the  stomach,  pain  is  similarly  relieved,  but  the  symptoms  are  never 
perfectly  typical.  It  is  in  this  type  of  case  that  a  duodenal  ulcer 
may  be  diagnosed  and  a  gastric  one  found  ;  the  converse  rarely  or 
never.  Disease  of  the  gall-bladder  or  appendix  may  cause  hunger- 
pain.  It  may,  however,  be  laid  down  that  recurrent  attacks  of 
hunger-pain  are  always  due  to  a  definite  organic  lesion,  one  that  can 
be  dealt  with  surgically. 

Occasionally  the  ulcer  is  situated  in  the  second  part  of  the  duodenum. 
In  these  cases  the  symptoms  are  often  atypical,  and  jaundice  may 


364  THE   STOMACH   AND   DUODENUM 

occur.  I  have  recorded  cases  of  this  nature  in  which  it  was  im- 
possible to  make  a  certain  diagnosis  between  duodenal  ulcer  and 
gall-stones. 

Complications. — Stenosis  of  the  pylorus  may  result  after 
many  years  ;  this  sequel  brought  the  patients  under  my  care  in  18 
out  of  70  cases  of  chronic  ulcer. 

Haemorrhage. — It  is  impossible  to  estimate  the  frequency  with 
which  bleeding  occurs.  The  blood  may  be  vomited,  but  generally 
only  appears  in  the  fasces.  Slight  haemorrhage,  such  as  may  be  dis- 
covered by  tests  for  "  occult  blood,"  is  probable  in  most  cases.  Craven 
Moore  found  it  in  all  the  cases  under  his  care.  Severe  haemorrhage 
is  a  late  and  serious  complication.  The  bleeding  may  come  on  without 
warning  and  cause  sudden  fainting,  followed  by  the  passage  of  a 
tarry  motion,  with  or  without  the  vomiting  of  blood.  In  other  cases 
it  may  occur  insidiously  without  the  knowledge  of  the  patient.  The 
bleeding  may  be  fatal,  the  source  of  the  blood  being  the  gastro -duodenal, 
superior  pancreatico-duodenal,  right  gastro-epiploic,  or  pyloric  arteries. 
In  a  few  cases  death  has  been  sudden. 

Jaundice  may  develop  as  the  result  of  the  cicatrization  of  ulcers 
of  the  second  part,  or  of  the  spread  of  inflammation  into  the  common 
bile-duct,  but  is  a  rare  complication. 

Pancreatitis  may  be  present,  due  to  a  spread  of  the  associated 
duodenal  inflammation.  In  a  large  number  of  cases  of  chronic  duo- 
denal ulcer  the  Cammidge  reaction  may  be  obtained. 

Diagnosis. — In  about  85  per  cent,  of  the  cases  the  typical 
character  of  the  recurring  attacks  of  hunger-pain  will  render  the 
diagnosis  almost  certain.  Difficulty  arises  in  those  which  do  not 
conform  to  this  type.  It  must  not  be  considered  that  hunger-pain, 
or  pain  two  or  three  hours  after  food  relieved  by  taking  food,  is  found 
only  in  association  with  duodenal  ulcer,  for  it  occasionally  occurs  also 
in  cases  of  gastric  ulcer.  In  cholelithiasis,  attacks  of  pain  two  or 
three  hours  after  food  may  cause  duodenal  ulcer  to  be  thought  of, 
but  in  these  cases  the  pain  is  not  relieved  by  a  warm  drink  or 
soda  bicarbonate,  as  in  duodenal  ulcer  ;  moreover,  in  cholelithiasis 
retching  and  vomiting  are  common,  whilst  they  are  usually  absent  in 
duodenal  ulcer. 

In  doubtful  cases  the  fseces  may  be  tested  for  traces  of  blood^ 
"  occult  "  heemorrhage. 

The  examination  of  the  gastric  contents  after  a  test  meal  is  of 
great  service  in  enabling  a  diagnosis  to  be  made.  Chronic  duodenal 
ulcer  uncomplicated  by  secondary  gastric  dilatation  is  associated 
with  an  excess  of  free  HC1  and  the  total  acidity  is  high.  In 
cholelithiasis  this  is  unusual ;  in  long-standing  cases  free  HC1  is 
usually  absent  and  the  total  acidity  is  low. 


DUODENAL    ULCER:    TREATMENT  365 

Prognosis.  -Chronic  ulcer  of  the  duodenum  is  a  grave  dia 
Its  mortality  after  uon-operative  treatment  has  not  been  winked  oul 
as  in  the  case  of  gastric  ulcer,  for  until  recently  it  was  only  recog- 
nized when  giving  rise  to  late  symptoms  haemorrhage,  perforation, 
01  stenosis.  It  is,  therefore,  quite  impossible  to  estimate  its  mortality 
accurately,  but  if  haemorrhage  or  perforation  has  occurred  the  death* 
rate  is  high. 

On  the  other  hand,  operative  treatment  not  only  offers  relief, 
but  enables  the  ulcer  to  heal. 

The  results  of  operation  are  extremely  good.  Moynihan,  between  1900 
and  1909,  operated  upon  228  patients,  with  a  death-rate  of  less  than  2  per 
cent.,  and  no  death  among  the  last  116  cases  ;  163  were  traced,  and  of  these 
144  were  cured  (79  per  cent.),  18  improved,  and  only  1  "  no  better."  Similarly, 
good  results  have  been  recorded  by  all  who  have  worked  at  the  subject. 
In  70  patients  with  chronic  ulcer  upon  whom  I  had  operated  up  to 
December,  1911,  there  was  1  death — from  "aspiration"  broncho-pneumonia. 
All  are  improved,  and  all  but  one  of  those  operated  on  over  two  years  ago 
are  quite  well. 

Treatment. — At  the  first  attack  the  patient  should  have  a 
thorough  trial  of  medical  treatment  with  rest  in  bed.  It  is  impossible 
to  estimate  the  prospect  of  success  by  this  treatmsnt,  but  it  has 
failed  to  cure  in  many  cases.  Ambulatory  treatment  is  certainly  a 
failure  ;  I  have  recently  operated  upon  2  patients  in  whom  perfora- 
tion had  occurred  while  under  this  treatment. 

Operation  should  be  carried  out  in  all  cases  of  duodenal  ulcer  in 
which  thorough  medical  treatment  has  failed  to  cure.  Although  the 
condition  was  first  treated  by  gastroenterostomy  by  Codevilla 
in  1893,  it  is  only  of  recent  years  that  its  correct  treatment  has  been 
recognized  owing,  in  great  measure,  to  the  work  of  Moynihan,  the 
Mayos,  and  Mayo  Robson. 

The  abdomen  should  be  opened  by  displacing  the  right  rectus 
muscle.  The  ulcer  is  usually  found  on  the  upper  and  anterior  part 
of  the  first  portion  of  the  duodenum.  The  peritoneum  over  it  pre- 
sents a  speckled  reddish  appearance,  and  a  definite  induration  can 
be  felt  between  the  finger  and  thumb.  When  the  ulcer  is  situated  on 
the  posterior  portion  of  the  duodenum,  it  may  usually  be  felt  through 
the  anterior  wall  or  by  picking  up  the  duodenum  between  ringer  and 
thumb.  In  many  cases  adhesions  are  present  binding  the  duodenum 
to  the  gall-bladder  or  liver.  In  every  case  in  which  the  condition 
of  the  patient  permits,  the  gall-bladder  and  appendix  should  be 
examined,  and  surgically  treated  if  necessary. 

After  examining  the  stomach  for  signs  of  ulcer,  posterior  no-loop 
gastrojejunostomy  should  be  carried  out.  That  this  is  sufficient 
in   most  cases    is    shown    not    only  by  the   long    series    recorded  in 


366  THE   STOMACH   AND   DUODENUxM 

which  absolute  relief   of   symptoms  occurred,  but  by  demonstration 
at  a  second  operation  performed  for  some  other  condition. 

In  one  patient  upon  whom  I  operated  the  ulcer  was  demonstrated  as 
healed  during  the  course  of  an  operation  undertaken  for  another  condition 
three  years  later.  At  the  operation  I  had  found  "  a  large  indurated  mass 
on  the  anterior  surface  of  the  first  part  of  the  duodenum  adherent  to  the 
liver."  The  surgeon  who  performed  the  second  operation  wrote :  "  The 
duodenum  was  quite  free  from  induration  and  was  loosely  adherent  to  the 
liver.  There  was  a  greyish-white  scar  on  its  anterior  surface  §  in.  from 
pylorus,  which  was,  however,  quite  soft  and  no  thicker  than  the  neighbouring 
gut.  The  anastomosis  was  quite  perfect,  with  the  mesocolon  merely  adherent 
to  the  suture  line."  In  another  patient  I  opened  the  abdomen  four  years 
later  for  another  condition,  and  found  that  the  ulcer  had  healed.  Similar 
cases  have  been  recorded  by  Moynihan. 

But  death  has  occurred  from  haemorrhage  or  perforation  after  a 
successful  gastrojejunostomy  had  been  performed,  and  Moynihan 
has  recorded  a  case  in  which,  on  opening  the  abdomen  three  years 
later  for  recurrence  of  symptoms,  two  recent  ulcers  were  found  close 
to  the  large  scar  of  the  old  one.  For  these  reasons  the  ulcer  should 
be  infolded  if  it  is  situated  on  the  anterior  surface ;  if  on  the  posterior, 
the  duodenum  should  be  obliterated  by  infolding  the  anterior  wall. 

The  after-treatment  should  be  similar  to  that  carried  out  in  chronic 
gastric  ulcer. 

Haemorrhage  must  be  looked  upon  as  a  serious  symptom,  and 
operation  carried  out  as  soon  as  the  patient  can  stand  it,  usually 
within  forty-eight  hours.  It  will  rarely  be  justifiable  to  operate 
during  the  course  of  the  bleeding,  but  if  the  patient  has  had  a 
severe  haemorrhage,  and  the  bleeding  recurs  while  he  is  absolutely 
at  rest,  operation  without  loss  of  time  is  indicated.  The  ulcer 
should  be  infolded,  the  gastro-duodenal  artery  ligatured,  and  gastro- 
jejunostomy done. 

Perforation  of  Duodenal  Ulcer 

It  has  been  stated  that  perforation  is  a  relatively  more  frequent 
accident  in  duodenal  than  in  gastric  ulcer,  but  this  is  impossible  of 
direct  proof,  for  we  have  no  means  of  knowing  the  number  of  patients 
suffering  from  this  lesion.  The  old  figures  (Chvostek,  42  per  cent.  ; 
Collin,  69  per  cent.)  certainly  over-state  the  frequency,  and  were 
compiled  before  our  present  knowledge  of  the  condition.  It  is  more 
common  than  in  chronic  gastric  ulcer,  for  chronic  duodenal  ulcer  is 
most  often  situated  on  the  anterior  and  upper  wall  of  the  duodenum. 
That  it  is  a  fatal  termination  and  not  infrequently  occurs  while  the 
patient  is  under  treatment  is  certain. 

The  perforation  is  more  common  on  the  anterior  wall  of  the  first 
part  of  the  duodenum — 90  per  cent,  of  the  cases.     (Fig.  380.) 


IH'ODKNAL    ULCER:     IM  1<1  ( )1< A  1  K  )N 


Symptoms. — A  few  years  ago i1  wasthoughl  ih.it  duodena]  ulcer 

sraa  often  latent,  and  that  the  first  symptom  was  iii  many  i 
Eoiation.  Now  that  the  symptoms  of  duodenal  ulcer  are  better  known, 
it  is  recognized  ( ba1  in  mos1 
symptoms  have  been 
presenl  for  years,  and  that 
the  ulcei  which  has  perfo* 
rated  is  a  chronic  one. 

Thus,  in  14  out  of  15  cases 
recorded  by  Mitchell,  a  his- 
tory of  previous  "  dyspepsia  " 
was  present,  in  the  majority 
of  the  cases,  typical  of 
chronic  ulcer.  I  have  found 
the  same  in  most  of  the 
cases  of  perforation  in  which 
I  made  careful  inquiries ; 
the  last  four  occurred  while 
the  patient  was  under  me- 
dical treatment. 

The  perforation  may  be 
acute,  subacute,  or  chronic. 
It  is  much  more  frequently 
subacute  than  in  gastric- 
ulcer,  and  consequently  the 
symptoms  may  not  be  so 
definite  as  those  of  a  per- 
forated gastric  ulcer. 

If  the  ulcer  is  situated 
close  to  the  pylorus,  and  the 
opening  is  a  large  one,  there 
is  a  sudden  escape  of  gastric 
contents,  causing  severe  epi- 
gastric pain,  followed  by  ab- 
dominal rigidity,  with  the 
same  absence  of  early  severe 
shock  as  in  perforation  of  a 
gastric    ulcer.     But    if    the 

perforation  is  a  small  one,  or  is  situated  at  the  junction  of  the  first 
and  second  parts  of  the  duodenum,  or  in  the  second  part,  the  escaped 
fluid  may  track  down  into  the  right  kidney  pouch.  Maynard  Smith 
has  experimentally  investigated  the  course  taken  by  fluids  escaping 
from  the  duodenum,  with  results  corresponding  to  those  found  clinically. 
The  fluid  in  every  case  ran  down  and  collected  in  the  right  kidney 


Fig.  380. — Perforation  of  an  acute  ulcer 
situated  on  the  anterior  wall  of  the 
first  part  of  the  duodenum.  Small 
chronic  ulcer  on  the  posterior  wall ; 
stomach  and  duodenum  opened 
from  above. 

(London  Hospital  Pathological  Institute.) 


36S  THE   STOMACH   AND    DUODENUM 

pouch,  then  passed  down  along  the  outer  side  of  the  ascending  colon 
as  far  as  the  pelvis,  and  overflowed  into  this. 

In  these  cases  the  symptoms  are  by  no  means  typical,  and.  in 
the  absence  of  a  previous  history  pointing  to  duodenal  ulcer,  are 
very  liable  to  be  mistaken  for  appendicitis.  It  should  be  borne  in 
mind  that  the  two  diseases  may  coexist,  and  that  cases  of  simul- 
taneous perforation  of  a  duodenal  ulcer  and  acute  appendicitis  are 
not  unknown. 

Thus,  there  are  two  types  of  perforation — those  hi  which,  from 
the  immediate  symptoms,  the  diagnosis  of  a  perforated  peptic  ulcer 
is  possible  ;  and  those  in  which  the  onset  is  more  gradual,  the  symp- 
toms that  bring  the  patient  under  observation  resembling  those  of 
appendicitis  or  subphrenic  abscess.  Fortunately  the  first  is  the 
larger  group. 

Diagnosis. — In  the  first  group  the  diagnosis  cannot  be  made 
from  a  perforated  gastric  ulcer  except  on  the  previous  history.  In 
the  cases  with  subacute  symptoms  of  perforation  or  with  signs  resem- 
bling those  of  appendicitis,  only  the  greatest  care  in  eliciting  the  pre- 
vious historv  and  the  history  of  the  onset  of  the  lesion  will  enable  the 
diagnosis  to  be  made.  In  most  cases  this  will  be  possible  ;  the  onset 
of  "  acute  abdominal "  symptoms  in  an  adult  male  should  always 
raise  the  suspicion  that  the  duodenum  is  at  fault. 

Occasionally  the  perforation  is  retroperitoneal,  with  the  gradual 
formation  of  a  swelling  in  the  right  loin,  usually  associated  with 
contraction  of  the  psoas  muscle.  The  abscess,  as  in  a  case  recorded 
by  Wagner,  may  simulate  a  psoas  abscess  due  to  spinal  disease,  and 
may  point  in  the  inguinal  region.  There  is  no  absolutely  sudden 
onset,  but  pain  with  a  raised  temperature.  If  the  previous  symptoms 
of  ulcer  have  not  been  typical  the  diagnosis  is  not  made  until  after 
the  abscess  has  been  opened  and  a  duodenal  fistula  forms.  These 
cases  are  rare  ;  one  successfully  treated  by  operation  has  been  recorded 
by  Lawford  Knaggs. 

It  might  be  supposed  that  if  the  abdomen  has  been  opened  on  the 
diagnosis  of  a  perforated  peptic  ulcer  no  further  difficulty  will  arise, 
vet  in  one  such  case  the  discovery  of  fat  necrosis  at  the  root  of  the 
mesentery  led  me  to  abandon  further  search.  In  this  case  an  ulcer 
of  the  second  part  of  the  duodenum  had  perforated  and  permitted 
the  escape  of  pancreatic  juice  into  the  peritoneal  cavity.  A  similar 
instance  of  fat  necrosis  associated  with  a  perforated  duodenal  ulcer 
has  been  since  recorded  by  H.  M.  Richter. 

Treatment. — The  abdomen  should  be  opened  through  the  right 
rectus  muscle.  As  a  rule  the  ulcer  is  at  once  seen.  It  should  be 
infolded  and  gastrojejunostomy  performed  if  the  condition  of  the 
patient  admit.     After   examining  for  further  perforations  the   right 


DUODENAL    ULCER:    PKRFORATION  369 

kidney  pouch  should  be  carefully  Bponged  out  and  the  abdomen  closed. 
If  necessary  the  right  renal  pouch  is  to  be  drained,  and,  in  addition, 
if  there  has  been  extensive  peritoneal  soiling,  a  tube  may  be  placed 
saprapnbically.  The  after-treatment  follows  the  lines  laid  down  for 
cases  of  perforated  gastric  ulcer  (p.  358). 

Prognosis. — At  the  present  time,  owing  chiefly  to  the  less 
acute  onset  of  many  cases  of  perforation,  the  death-rate  is  higher 
than  in  similar  perforations  of  the  stomach. 

Mayo  Robson  collected  155  cases,  with  a  mortality  of  66  per  cent. ;  daring 
1899-190S.  42  cases  were  operated  upon  at  the  London  Hospital,  with  a 
death-rate  of  80  per  cent.;  up  to  December,  1911,  I  had  operated  upon 
20  cases,  with  9  recoveries. 

A.  B.  Mitchell  of  Belfast  has  published  a  series  of  16  consecutive  opera- 
tions for  perforation,  without  a  single  death.  Of  these  cases,  11  were  operated 
upon  within  12  hours  of  perforation,  6  within  5  hours,  1  each  at  17£,  18, 
J"..  36,  and  49  hours  after  perforation.  In  my  own  cases,  successful  results 
attended  operations  done  4.  5,  6J,  7,  12,  14,  17,  "20,  and  21  hours  after 
perforation,  whilst  death  followed  those  performed  after  6  days,  5  days, 
4  days,  3  days,  70  hours,  65  hours,  40  hours,  30  hours,  25  hours,  12  hours, 
and  6  hours  respectively.  In  this  last  case  I  found  fat  necrosis  and  did 
not  search  for  the  duodenal  perforation. 

The  death-rate  in  the  first  29  cases  recorded  in  1899  (Pagenstecher) 
was  nearly  86  per  cent.,  and  the  mortality  has  been  gradually  falling. 
As  knowledge  of  the  early  symptoms  which  accompany  perforation 
becomes  widely  spread,  earlier  operation  will  render  treatment  more 
successful,  and  recognition  of  chronic  duodenal  ulcer  will  lead  to  the 
prevention  of  perforation  by  appropriate  treatment. 

HiEMATEMESIS 

Hsematemesis  occurs  in  many  diseases,  in  the  majority  of  which 
there  is  a  definite  lesion  of  the  stomach,  but  it  may  arise  secondarily 
in  cirrhosis  of  the  liver  or  in  Banti's  disease. 

In  cirrhosis  of  the  liver  the  bleeding  usually  takes  place  from  a 
ruptured  oesophageal  varix.  As  shown  by  Preble,  in  over  two-thirds 
of  the  cases  the  bleeding  was  the  first  symptom  calling  attention  to 
the  disease.  In  Banti's  disease  the  history  of  anaemia  and  the 
presence  of  the  enlarged  spleen  will  lead  to  the  correct  diagnosis. 

Cases  of  haomatemesis  fall  into  three  groups  :  (1)  Those  in  which. 
the  bleeding  is  the  first  obvious  symptom  of  disease.  (2)  Haema- 
temesis  occurring  after  operation.  (3)  Hsemateniesis  occurring  in 
patients  presenting  the  symptoms  of  chronic  gastric  or  duodenal  ulcer. 

1.  Bleeding  without  Premonitory  Symptoms 
In  this  group  the  patients  are  usually  young  amemic  women.    The 
ha-morrhage  is  the  first  symptom  in  75  per  cent,  of  the  casts  ;    in  the 
remainder  it  may  have  been  preceded  for  a  few    days  or  weeks  by 


3/o  THE   STOMACH   AND   DUODENUM 

symptoms  suggestive  of  gastric  ulcer.  The  haemorrhage  is  alarming 
and  profuse,  but  is  very  rarely  fatal.  Turner  has  stated  that  the 
death-rate  is  only  1-7  per  cent,  when  medically  treated  ;  this  corre- 
sponds with  my  experience. 

Instances  have  been  recorded  in  which  at  operation  or  at  the 
post-mortem  examination  no  ulcer  could  be  discovered.  Hale  White 
collected  29  such  examples  of  this  condition,  and  suggested  for  it 
the  name  gastrostaxis. 

It  is  difficult  to  examine  the  interior  of  the  stomach  satisfactorily 
during  life,  and  recent  acute  ulcers  or  erosions  are  easily  overlooked 
even  post  mortem  unless  the  stomach  be  carefully  examined  with  a 
lens.  It  is  probable  that  there  is  a  definite  lesion  of  the  mucous 
membrane  in  all  the  cases  in  this  group. 

Charles  Miller  has  described  swelling  and  necrosis  of  the  lymphoid 
follicles  in  cases  of  this  description  in  which  the  patient  died  from 
haemorrhage  or  the  operation  for  it.  Fred.  J.  Smith  has  found  small 
ulcers,  hardly  visible  to  the  naked  eye,  leading  directly  into  blood-vessels. 

Treatment. — Operation  should  never  be  undertaken  in  these 
cases.  The  death-rate  after  operation  is  over  60  per  cent.,  and  the 
bleeding  has  recurred  after  all  forms  of  treatment. 

Absolute  rest  in  bed  should  be  insisted  upon  and  a  hypodermic 
of  morphia  given.  High  rectal  injection  of  hot  water  from  112°  to 
120°  F.  (Tripier),  repeated  once  or  twice,  may  be  useful.  Nothing 
should  be  given  by  mouth  for  forty-eight  hours,  salines  being  given 
per  rectum  every  six  hours.  At  the  end  of  forty-eight  hours  feeding 
may  be  carefully  begun,  small  quantities  of  albumin-water  being 
first  given,  and  the  quantity  gradually  increased  if  well  taken,  followed 
by  Benger's  food  or  milk-and-water. 

2.  Postoperative  H^ematemesis 

Haemorrhage  from  the  stomach  occurs  occasionally  after  operation 
upon  the  abdomen,  and  in  rare  instances  after  operations  upon  other 
parts  of  the  body.  In  most  cases  the  operation  has  been  for  some 
septic  condition.  In  these  cases  the  general  condition  of  the  patient 
is  bad  and  indicative  of  a  severe  toxaemia.  In  most  instances  the 
haematemesis  occurs  within  twenty-four  hours  of  the  operation, 
although  it  may  be  delayed,  particularly  in  such  cases  as  appendicitis 
in  which  there  is  prolonged  sepsis.  As  a  rule  the  blood  vomited  is 
altered  in  colour,  and  the  name  l:  black  vomit  "  has  been  given  to  it. 

The  death-rate  of  this  condition  is  high.  Purves  estimated  it 
at  69  par  cent.  This  is  in  accordance  with  experience  at  the  London 
Hospital. 

Several  theories  have  been  put  forward  with  regard  to  its  causa- 
tion :    (1)  That  it  is  due  to  sepsis.     (2)  That  it  is   "dependent  on 


POSTOPERATIVE   HiEMATEMESIS  371 

1   reflex  nervous  influence"  (Mayo  Robson).     (3)  Thai   it    Lb  due  to 
injury  to  the  omentum    (v.  Biselsbsrg).     (4)  That  it   is  due  to   the 

amest  hetic. 

Sepsis,  as   iirst   shown   by  Rodman,   is  tin'  cause   in  most  c 
It  is  now  known  that  gastric  erosions  and  gastric  ulcers  are  relatively 
common   complications   of   septic    conditions.     The    hemorrhage   has 
thr  same  origin  as  thai  in  the  first  group,  from  definite  lesions  of  the 
mucous  membrane  of  the  stomach. 

Thus,  during  the  years  1907-9,  19  acute  ulcers — 18  of  stomach  and 
1  of  duodenum — were  found  at  the  Pathological  Institute  of  the  London 
Hospital  in  patients  who  died  shortly  after  operation.  In  none  of  these  cases 
had  haematemesis  or  melaena  occurred.  In  12  the  operations  had  been 
undertaken  for  acute  appendicitis,  in  3  for  acute  intestinal  obstruction, 
in  1  for  infective  gangrene  of  the  leg,  in  1  for  papilloma  of  bladder  in  a  patient 
witli  pyuria,  and  in  2  for  disease  of  the  gall-bladder.  During  the  same 
period  8  patients  died  with  postoperative  haematemesis.  In  3  cases  it 
originated  after  operation  for  acute  appendicitis,  in  2  after  operation  upon 
the  gall-bladder,  and  in  1  each  after  external  urethrotomy,  hysterectomy, 
and  epithelioma  of  tongue.  In  the  last  two  of  these  cases  the  haemorrhage 
arose  from  a  chronic  gastric  ulcer  which  had  eroded  the  coronary  artery, 
and  a  chronic  duodenal  ulcer  with  an  erosion  of  the  gastro-duodenal  artery. 
Of  the  remainder,  in  1  case  erosions  were  found  in  the  duodenum,  in  2  cases 
an  acute  gastric  ulcer  was  found,  in  1  a  bleeding  erosion  was  discovered  at 
operation,  in  1  no  cause  could  be  found  post  mortem,  in  another  no  post- 
mortem was  obtained. 

Postoperative  haematemesis  is  the  result  of  septic  gastritis  in  the 
majority  of  cases,  but  hsematemesis  may  occur  from  a  chronic  ulcer 
which  has  been  in  existence  for  some  time  without  giving  rise  to 
symptoms  sufficiently  severe  to  need  treatment.  ManseU-Moullin 
has  recorded  a  case  in  which  a  young  man  aged  23  died  from  profuse 
hsematemesis  forty-eight  hours  after  an  exploratory  incision  made 
in  the  left  iliac  fossa  for  inoperable  carcinoma  ;  at  the  post-mortem 
no  cause  was  found  in  the  stomach,  but  it  is  possible  that  an 
erosion  was  overlooked. 

Treatment. — Patients  in  whom  this  condition  arises  arc  always 
desperately  ill.  If  the  vomit  is  black,  frequent,  and  small  in  amount, 
gentle  lavage  with  warm  water,  to  which  3i  of  bicarbonate  of  soda 
to  the  pint  has  been  added,  should  be  employed,  and  repeated  if 
necessary.  The  toxaemia  should  be  combated  by  continuous  saline 
injection  per  rectum. 

3.     ELSMATEMESIS    FROM    A    CHBONIC    GASTRIC    OR    DUODENAL     ULCER 

This  is  a  serious  complication  and  leads  not  infrequently  to  a 
fatal  result.  Cecil  Wall  investigated  the  death-rate  among  the 
patients  admitted  into  the  London  Hospital  with  hsematemesis  due 
to   chronic   gastric    ulcer,    and    found    that    it    was    V2\    per    cent,    in 


372  THE   STOMACH   AND   DUODENUM 

men,  6|  per  cent,  in  women.  It  is  not  yet  sufficiently  realized  that 
death  from  this  cause  is  common.  The  bleeding  occurs  usually  from 
an  artery  of  medium  size,  although  it  may  take  place  as  the  result  of 
ulceration  into  a  vein.  A  small  aneurysm  often  forms  on  an  artery 
exposed  in  the  floor  of  the  ulcer,  ruptures,  and  gives  rise  to  profuse 
bleeding,  the  artery  being  unable  to  retract.  The  hsematemesis  may  be 
acute  and  lead  to  death  so  rapidly  that  there  is  no  time  for  surgical 
treatment ;  this  was  the  result  in  8  out  of  54  fatal  cases  collected  by 
Savariaud  :  in  these  cases  it  most  often  occurs  from  the  splenic  artery. 
Usually,  however,  the  bleeding  ceases  spontaneously,  only  to  recur 
later,  with  perhaps  a  fatal  result.  The  coronary,  pancreatico-duodenal, 
and  right  gastro-epiploic  are  the  usual  sources  of  the  bleeding. 

Treatment. — In  this  group,  unlike  the  first,  operation  must 
be  carried  out  in  all  cases.  It  must  be  undertaken  as  soon  after  the 
cessation  of  the  first  bleeding  as  the  patient's  condition  will  permit ; 
this  will  usually  be  in  thirty-six  to  forty-eight  hours.  During  this 
time  absolute  rest  and  the  avoidance  of  oral  feeding  are  essential. 
If  in  spite  of  this  treatment  the  bleeding  continues  or  recurs,  opera- 
tion should  be  resorted  to  without  delay.  During  the  period  of 
waiting  after  the  first  attack,  a  careful  watch  must  be  kept  to  see 
that  bleeding  is  not  continuing  although  no  blood  is  being  vomited. 

In  this  group  the  blood  is  usually  escaping  from  an  artery ;  direct 
treatment  of  the  bleeding-point  is  therefore  necessary.  It  has  been 
stated  that  gastrojejunostomy  is  sufficient  to  arrest  the  bleeding  ; 
this  is  probably  true  when  the  blood  is  coming  from  a  small  vessel, 
but  there  is  no  way  of  telling  the  size  of  the  vessel,  and  it  is  safer  to 
treat  the  ulcer  directly.  That  gastrojejunostomy  is  not  sufficient 
to  arrest  arterial  haemorrhage  is  seen  in  the  cases  in  which  fatal 
hseinatemesis  from  an  artery  in  the  floor  of  a  chronic  ulcer  occurs  some 
weeks  after  a  successful  gastrojejunostomy.  In  a  case  under  my 
care  in  which  this  happened,  gastrojejunostomy  was  performed  in  a 
patient  with  a  large  saddle-shaped  ulcer  of  stomach  which  had  per- 
forated anteriorly  and  was  firmly  adherent  to  the  pancreas  posteriorly. 
The  patient  did  extremely  well  until  the  day  on  which  he  was  to  leave 
hospital,  a  month  after  operation,  when  he  had  a  fatal  hsematemesis. 
At  the  post-mortem  examination  the  ulcer  had  healed  anteriorly, 
but  posteriorly  the  pancreas  was  exposed  in  the  floor  of  the  ulcer 
and  a  small  aneurysm  of  the  splenic  artery  had  ruptured. 

After  opening  the  abdomen,  the  stomach  should  be  carefully 
examined,  and  if  an  ulcer  is  seen  on  the  lesser  curvature  it  should, 
if  possible,  be  infolded,  after  ligature  of  the  vessel  on  either  side  of 
it,  or  excised.  If  this  is  impossible  from  its  size  or  the  presence  of 
adhesions,  or  if  the  ulcer  is  situated  on  the  posterior  surface  of  the 
stomach  and  adherent  to  the  pancreas,  the  stomach  should  be  opened, 


PERIGASTRIC   ABSCKSS 


373 


fche  floor  of  fche  ulcer  carefully  examined,  and  any  vessels  which  have 
raptured  tied  on  both  sides.  In  one  case  I  was  able  successfully  t<> 
ligate  on  both  sides  of  an  opening  in  a  Large  artery  in  the  floor  of  an 
ulcer  on  the  posterior  wall.  If  the  condition  of  the  patient  permits, 
gastrojejunostomy  should  be  done  at  the  same  time. 

If  the  ulcer  is  duodenal,  it  should  be  infolded,  and  the  gastro-duo- 
denal  artery  tied  ;  if  on  account  of  adhesions  or  ulceration  the  anterior 
wall  cannot  be  satisfactorily  infolded  so  as  to  press  upon  the  affected 
vessel  (usually  the  gastro-duodenal),  the  gut  should  be  opened  and 
i  he  vessel  ligated.     Posterior  gastrojejunostomy  should  then  be  done. 

If  the  stomach  appears  to  be  normal,  no  operation  should  be 
performed,  but  the  abdomen  closed. 

PERIGASTRIC   ABSCESS 

This  is  usually  due  to  the  perforation  of  a  chronic  gastric  ulcer, 
or  to  imperfect  drainage  of  the  abdominal  cavity  after  operation  for 
perforation. 

When  a  perigastric  abscess  is  the  result  of  an  ulcer  on  the  anterior 
wall  of  the  stomach,  this  viscus   forms  the  lower  boundary  of  the 


Fig.  381. — Diagrams  to  illustrate  abscess  in  left  anterior 
intraperitoneal  fossa.     (Barnard.) 

abscess  cavity,  the  gastro-hepatic  omentum  the  posterior  wall,  and 
the  liver  the  upper  wall.  Such  an  abscess  may  burst  through  the 
skin,  or  may  open  into  the  colon,  causing  a  gastro-colic  fistula,  or 
may  become  subphrenic. 

As  a  rule,  ulcers  which  perforate  chronically  are  situated  on  the 
posterior  surface  of  the  stomach,  and  a  subphrenic  abscess  results 
(p.  572). 


374 


THE   STOMACH   AND    DUODENUM 


Subphrenic  abscess  (see  also  p.  572)  is  most  commonly  caused  by 
perforation  of  a  gastric  or  duodenal  ulcer.  Of  76  cases  recorded 
bv  Barnard,  it  was  due  to  this  cause  in  26,  the  ulcer  being  gastric 
in  21  and  duodenal  in  5  cases.  The  fossa  affected  is  usually  the  left 
anterior  intraperitoneal  (Barnard).  This  fossa  is  bounded  above  by 
the  diaphragm,  below  and  to  the  right  by  the  left  lobe  of  the  liver, 
on  the  left  bv  the  spleen,  and  below  by  adhesions  of  the  omentum  to 
the  abdominal  wall  (Fig.  381).     Signs  of  interference  with  the  base 

of  the  left  lung  are  usually  present. 
An  abdominal  swelling  can  be  re- 
cognized occupying  a  triangular  area 
limited  by  the  costal  margin  on  the 
outer  side,  and  by  a  line  convex 
to  the  right  joining  the  umbilicus 
to  the  ensiform  and  the  ensiform 
to  the  costal  margin.  Gas  is  usually 
present,  giving  rise  to  resonance  at 
the  upper  part  of  the  swelling  (Fig. 
381). 

When  the  perforation  is  at  the 
pylorus  or  in  the  duodenum  the  right 
anterior  intraperitoneal  space  may 
be  affected  (Fig.  382).  Of  27  ab- 
scesses of  this  type,  4  were  the  result 
of  perforation  of  a  gastric  and  2  of 
the  perforation  of  a  duodenal  ulcer. 
This  fossa  is  situated  between  the 
diaphragm  above,  the  right  lobe  of 
the  liver  below,  and  the  falciform  ligament  to  the  left. 

The  right  posterior  fossa  (subhepatic  fossa,  right  renal  fossa)  is 
rarely  affected.  Of  10  abscesses  in  this  situation.  1  was  due  to  a 
gastric  and  1  to  a  duodenal  ulcer. 

Rarely  the  abscess  involves  the  lesser  sac  (left  posterior  intraperi- 
toneal, Barnard)  ;  of  3  cases  of  this  nature  it  was  due  to  perforated 
gastric  ulcer  in  2,  but  the  lessor  sac  was  not  affected  alone. 

The  abscess  may  burst  spontaneously  into  a  bronchus,  into  the 
pleura,  with  the  formation  of  a  pyopneumothorax,  into  the  stomach 
or  intestine,  or,  rarely,  through  the  skin. 

Treatment. — If  the  presence  of  pus  beneath  the  diaphragm  is 
suspected,  careful  exploration  under  an  anaesthetic  must  be  undertaken. 
An  exploring  syringe  having  a  needle  3  in.  long  should  be  used.  As 
recommended  by  Barnard,  search  should  first  be  made  in  the  scapular 
line,  from  the  10th  space  to  the  6th.  If  no  pus  is  found  here,  the 
spaces  in  the  mid-axillary  line  should  be  similarly  explored.     When 


Fig.    382. — Diagram    to    illus- 
trate   abscess   in    right   an- 
terior intraperitoneal   fossa. 
Barnard. 


GASTKIC    FIBROMA 


375 


pus  is  found  the  rib  below  should  be  resected,  tin-  diaphragm  fixed 
to  the  intercostal  muscles  with  catgut  stitches,  and  the  abs<  ess  opened 
and  drained. 

Anterior  abscesses  should  only  be  drained  from   the  front   when 
no  pus  is  discovered  by  thorough  posterior  exploration. 


BENIGN   TUMOURS 

Benign   tumours   of   the   stomach    and  duodenum    are   rare,  and 
in  iv  be  divided  into  three  groups  : — 

1.  Connective-tissue  tumours. 

2.  Glandular  tumours  (adenomas). 

3.  Cysts. 

1.  CONNECTIVE-TISSUE   TUMOURS 
This  group  of  tumours  includes — i.  Fibromas.     ii.  Fibro-myomas. 

iii.  Lipomas.  .    „ 

r  i.  Fibromas 

These  are  rarely  met  with.     They  may  occur  as  polypoid  tumours 
in  the  pyloric  region,  single  or  multiple.     (Fig.  383.) 

Thev  may  be  encapsuled  in  the  gastric  wall,  as  in  the  case  reported 


Fig.  383. — Fibroma  of  stomach. 

(London  Hospital  Museum.) 

by  \Y.  G.  Spencer  in  which  he  successfully  removed  a  fibroma  weighing 
7  oz.  from  the  posterior  wall  of  the  stomach  of  a  woman  of  46. 

According  to  Fenwick,  no  case  hitherto  recorded  has  been  above 
suspicion  of  malignancy. 

Treatment.— Pedunculated  tumours  should  be  removed  by 
cutting  through  the  pedicle  and  suturing  the  mucous  membrane. 
When  embedded  in  the  gastric  wall  they  should  be  enucleated  or 
excised  with  the  affected  part  of  the  stomach. 

ii.  Myomas  and  Fibro-Myomas 
These  constitute  the  commonest  variety  of  simple  tumour  of  the 
stomach ;    61   cases   (Thomson   of    Galveston)   have   been    published 
since  the  first  was  recorded  bv  Morgagni  in  1762. 


376 


THE   STOMACH   AND   DUODENUM 


Arising  in  the  muscular  tissue,  usually  along  one  of  the  curvatures, 
they  are  mostly  single,  and  may  project  into  the  stomach  or  grow 
externally ;  the  internal  and  external  varieties  are  about  equally 
common.  Those  that  project  into  the  cavity  of  the  stomach  rarely 
attain  a  size  larger  than  a  -walnut ;  they  frequently  become  ulcerated, 
and  may  cause  hsematemesis  or  pyloric  obstruction.  The  external 
form  may  attain  a  large  size  and  may  con- 
tract adhesions  to  various  organs.  Herman 
has  recorded  the  successful  removal  of  a 
tumour  of  this  nature.  Similar  tumours 
may  arise  in  the  duodenum. 

The  condition  is  met  with  in  adult  life. 
Fen  wick  states  that  it  is  more  common  in 
males,  but  of  27  of  the  49  cases  analysed  by 
Deaver  and  Ashurst,  in  which  the  sex  was 
stated,  16  were  females. 

On  section  the  tumour  is  firm  and  of  a 
whitish  colour,  and  under  the  microscope  is 
seen  to  be  made  up  of  bundles  of  unstriped 
muscle  fibres  mixed  with  strands  of  fibrous 
tissue  concentrically  arranged. 

Myxomatous  degeneration  may  occur,  and 
cases  have  been  recorded  in  which  secondary 
growths  were  present  in  the  liver  and  in 
the  peritoneum.  Cysts  may  originate  from 
hemorrhage.  The  tumour  may  contain  an- 
giomatous or  adenomatous  tissue. 

Treatment.  —  When  "internal,"  a 
myoma  should  be  shelled  out,  or,  if  this  be 
impossible,  it  should  be  excised  together 
with  the  portion  of  gastric  wall  from  which 
it  springs.  When  external,  its  pedicle 
should  be  clamped  and  divided,  and  the 
stump  covered  with  peritoneum  after  ligature  of  the  necessary 
vessels. 

Twenty  operations  have  been  recorded  for  this  condition,  including 
2  in  which  gastroenterostomy  was  done  on  the  supposition  that  the 
tumour  was  malignant. 

iii.  Lipomas 

Fatty  tumours  may  originate  in  subserous  or  submucous  coats, 
usually  the  latter,  and  may  in  rare  instances  become  pedunculated. 
They  form  lobulated  tumours  projecting  into  the  stomach,  covered 
usually  by  healthy  mucous  membrane  (Fig.  384). 


Fig.  384. — Submucous 
encapsuled  lipoma  of 
stomach. 

(London  Hospital  Museum.} 


GASTRIC   ADENOMA  \77 

2.  ADENOMAS 

Under  (his  heading  arc  included  both  the  solitary  and  the  multiple 
pedunculated  tumours.  The  latter  are  usually  called  polyadenomas 
01  mucous  polypi.     (Fig.  385.) 

Adenomas  are  usually  found  in  the  pyloric  region,  and  constitute 
the  commonest  variety  of  gastric  polypi.  The  tumour  may  reach 
the  size,  of  an  apple,  and  may  produce  pyloric  obstruction,  as  in  the 


Fig.  385.— Mucous  polypi. 

(Royal  College  OJ  Surgeons  Museum.) 

cases  operated  upon  by  Mayo  Robson,  Moynihan,  and  Sir  William 
Bennett,  or  may  cause  fatal  intussusception. 

Multiple  mucous  polypi  are  more  common  in  men  than  in  women, 
are  rare  before  the  age  of  40,  and  are  generally  found  in  conjunction 
with  chronic  gastritis.  Rarely  larger  than  cherries,  they  are  evenly 
distributed  over  the  stomach,  and  may  extend  into  the  duodenum. 
The  greater  part  of  each  polypus  is  composed  of  mucous  membrane 
in  which  the  glands  are  dilated  and  tortuous,  while  frequently  they 
are  cystic. 

Treatment  follows  the  lines  as  laid  down  for  pedunculated 
tumours  elsewhere.  Six  cases  have  been  recorded,  in  5  of  which 
recovery  ensued. 

3.  CYSTS. 

Cysts  of  the  stomach  are  rare.     They  may  occur  in  consequence 


378  THE   STOMACH   AND   DUODENUM 

of  injury  (traumatic  cysts),  or  as  the  result  of  degeneration  of  tumours 
(degeneration  cysts)  ;  while  hydatid  cysts  may  develop  in  the  wall 
of  the  stomach,  and  in  one  instance,  recorded  in  1732,  a  dermoid  cyst 
was  said  to  be  present.  Retention  cysts  may  arise  from  the  obstruc- 
tion of  ducts  in  chronic  gastritis,  but  they  are  devoid  of  clinical 
importance.  Gastric  cysts  produce  symptoms  which  resemble  those 
of  other  benign  tumours,  but  in  addition  they  are  liable  to  rupture 
or  to  become  infected,  causing  a  perigastric  abscess  or  general 
peritonitis. 

Symptoms  of  benign  tumours. — In  many  cases  benign 
tumours  give  rise  to  no  symptoms  unless  they  obstruct  the  pyloric  or 
cardiac  orifices  ;  but  if  large  and  situated  in  the  body  of  the  stomach 
they  may  cause  pain  of  a  dragging  character.  Vomiting  is  unusual 
unless  the  tumour  obstructs  the  pylorus.  Hsematemesis  may  arise 
in  adenomas  or  in  myomas,  when  the  mucous  membrane  covering 
them  has  become  ulcerated. 

Diagnosis  of  benign  tumours. — The  possibility  of  a 
tumour  being  benign  should  be  remembered,  for  unnecessarily  severe 
operations  have  been  performed — for  example,  partial  gastrectomy 
for  myoma. 

MALIGNANT  TUMOURS 

CARCINOMA   OF   THE    STOMACH 

This  is  a  disease  of  appalling  frequency.  It  has  been  estimated  to  be 
the  cause  of  death  in  over  4,000  people  in  England  annually  ;  during  the 
years  1897-1904,  36,331  deaths  were  registered  as  due  to  gastric  cancer. 
Dowd  states  that  9,000  deaths  from  cancer  of  the  stomach  were  recorded 
in  the  United  States  in  1900.  Virchow  estimated  that  nearly  35  per  cent, 
of  all  cancers  that  terminated  fatally  originated  in  the  stomach.  Haberlin, 
analysing  the  records  of  over  27,000  cases  of  carcinoma,  found  that  41  per 
cent,  were  connected  with  the  stomach.  In  England  and  Wales  it  is  the 
seat  of  disease  in  22  per  cent,  of  the  fatal  cases. 

Etiology. — Carcinoma  of  the  stomach  may  be  met  with  at  any 
age,  but  is  most  common  between  the  ages  of  40  and  70. 

Thus,  in  230  cases  of  carcinoma  of  the  stomach  admitted  to  the  London 
Hospital  between  the  years  1899-1908.  in  which  the  diagnosis  was  verified 
by  operation  or  post-mortem  examination,  196  occurred  during  this  period, 
the  greatest  number  being  between  50  and  60.  From  a  study  of  2,604  post- 
mortems on  patients  who  had  died  from  gastric  carcinoma,  Fenwick  found 
the  age  of  death  to  be  between  60  and  70  in  77  per  cent,  of  the  cases.  It 
is  rare  under  20,  according  to  Osier  and  McCrae  2-5  per  cent.,  but  among 
the  London  Hospital  cases  only  1  was  below  the  age  of  20.  Six  cases  have 
been  reported  in  children  under  10,  but  of  these  only  2  can  be  definitely 
claimed  as  examples  of  carcinoma. 

5ex. Men  are  affected  more  frequently  than  women.     Fenwick  found 


GASTRIC   CARCINOMA:    ETIOLOG1  379 

dial  in  :;.iiT!»  poel  mortem  examinations  on  oases  of  gastric  cancer, 
i.e.  60  per  cent,  of  the  Bubjeots    were  males. 

Race.   -Bainbridge  lias  Btated  thai  the  black  ran-,  are  almost  immune, 

and  cancer  of   die   stomach  fa  said  to  i>e  practically  unknown  among   tin 
Datives  in  Natal,  Gambia,  and  West  Africa. 

Gastric  ulcer. — It  is  held  by  all  Burgeons  who  have  worked  at 
the  question  that  chronic  gastric  ulcer  predisposes  to  the  development 
of  gastric  carcinoma.  Evidence  of  this  has  Keen  gradually  accumulat- 
ing since  its  possibility  was  first  discussed  by  Cruveilhier  in  1839,  and 
Bpkitansky  a  year  later.  Dittrich,  in  1848,  described  G  cases  in  which 
carcinoma  developed  in  the  immediate  vicinity  of  active  or  healed 
ulcers.  The  evidence  of  the  relationship  has  of  late  been  entirely 
surgical  ;  in  fact,  physicians  generally  have  been  somewhat  sceptical 
with  regard  to  it. 

Osier  and  McCrae  in  1900,  in  their  work  on  "Cancer  of  the  Stomach," 
found  that  in  only  4  out  of  150  cases  was  there  a  history  of  ulcer  ;  they  say  : 
'"  We  may  conclude,  so  far  as  the  figures  show  anything,  that  the  victims 
of  chronic  dyspepsia  and  the  various  forms  of  gastritis  are  not  more  prone 
to  malignant  disease  than  other  individuals."  The  great  development  ot 
gastric  surgery  since  that  date  has  led  to  other  views.  Among  87  patients 
with  carcinoma  of  the  stomach  upon  whom  I  operated  up  to  December, 
1911,  there  was  in  31  a  definite  history  pointing  to  chronic  gastric  ulcer, 
symptoms  having  been  present  for  from  five  to  twenty-eight  years.  Mayo 
Robson,  in  cases  in  which  he  operated,  found  a  suggestive  history  in 
59  per  cent.  :  Moynihan,  in  60  per  cent.  Mumford  and  Stone  traced  60 
patients  who  had  been  treated  at  the  Massachusetts  General  Hospital  for 
"  chronic  indigestion,"  and  subsequently  died,  no  less  than  half  with  gastric 
cancer. 

The  most  convincing  evidence  has  been  put  forward  by  Wilson  and 
MacCarty  as  the  result  of  their  examination  of  specimens  removed  by 
operation  in  the  Mayos'  clinic.  In  71  per  cent.  (109  out  of  153  cases)  there 
was  naked-eye  and  microscopical  evidence  that  carcinoma  had  developed 
from  pre-existing  ulcers. 

The  facts  that  carcinoma  and  chronic  gastric  ulcer  are  both  more 
common  in  men  than  in  women,  and  that  they  have  their  usual  seat 
in  the  same  part  of  the  stomach,  are  suggestive  of  a  close  relationship 
between  them. 

There  can,  in  my  opinion,  be  no  doubt  that  gastric  ulcer  is  a  pre- 
disposing cause  of  cancer  of  the  stomach  in  a  large  proportion  of  cases. 

Pathology.  —  Carcinoma  may  start  primarily  in  the  stomach 
or  affect  it  secondarily.  The  secondary  variety  is  comparatively  rare 
and  of  little  surgical  importance  ;  it  occurred  in  7  per  cent,  of  the 
265  post-mortem  examinations  of  cancer  of  the  stomach  recorded  by 
Fenwick,  and  Hale  White  states  that  it  occurs  in  6  to  7  per  cent,  of 
the  cases.  In  the  other  published  series  the  percentage  has  been  as 
low  as  1,  which  is  in  agreement  with  experience  at  the  London 
Hospital. 


380  THE    STOMACH    AND    DUODENUM 

Gastric  '  rcinoma  arises  most  often  as  tlie  result  of  direct  exten- 
sion from  the  pancreas,  colon,  or  pall-bladder,  or  from  the  oesophagus. 
In  this  Lrroup  must  also  be  placed  those  cases,  by  no  means  un- 
common, following  carcinoma  of  the  breast.  It  may  be  secondary  to 
carcinoma  of  the  upper  alimentary  tract  (auto-inoculation).  More 
rarely  still  does  it  arise  as  a  metastasis. 

Primary  carcinoma  of  the  stomach  may  be  composed  of  spheroidal 
or  cylindrical  celLs  ;  either  may  undergo  colloid  degeneration.  If 
the  fibrous  stroma  is  abundant,  the  adjective  "  scirrhns  '''  is  applied; 
if  small  in  amount,  the  growth  is  known  as  a  "  medullary  "  or  "  en- 
cephaloid  ::  carcinoma. 

In  spheroidal-celled  carcinoma  the  cells  resemble  those  of  the 
gastric  tubules  ;  this  variety  is  more  than  twice  as  common  as  the 
cylindrical  or  columnar-celled  (Perry  and  Shaw,  Fenwick),  and  is 
the  usual  type  of  "  malignant  ulcer."  It  was  found  by  Fenwick 
to  be  "  hard  "  in  19  out  of  41  cases.  *'  Colloid  :;  carcinoma — the 
result  of  a  mucoid  or  colloid  degeneration  which,  though  usually 
affecting  the  cells,  may  affect  the  stroma  as  well — is  found  in 
about  7  per  cent,  of  cases.  Neither  form  has  a  special  preference 
for  any  portion  of  the  stomach,  but  the  columnar-celled  variety  is 
most  common  in  the  pyloric  region,  where  it  usually  springs  as  a 
soft  red  fungoid  growth.  Either  form  may  infiltrate  the  whole  organ 
("leather-bottle"  stomach),  rendering  it  small  in  the  spheroidal- 
celled  variety,  rarely  diminishing  its  size  in  the  columnar.    (Fig.  386.) 

Situation. — The  older  authorities  were  of  opinion  that  60  per 
cent,  of  all  gastric  cancers  are  situated  at  the  pylorus.  But  modem 
observations  show  that  the  percentage  is  not  so  great  as  this  ;  Boas,  in 
125  rases,  found  the  pylorus  affected  in  34  (27  per  cent.),  while  in 
87  eases  upon  which  I  have  operated  the  growth  was  on  the  lesser 
curvature  in  52.     The  cardiac  end  is  affected  in  9-8  per  cent.  (Fenwick). 

Growths  are  occasionally  multiple  ;  in  most  of  the  recorded  cases 
they  have  been  on  opposed  surfaces  of  the  viscns. 

Carcinoma  commences  in  the  deeper  layers  of  the  mucous  mem- 
brane ;  if  at  the  edge  of  an  ulcer,  it  is  usually  in  that  edge  nearest 
the  pylorus. 

Method  of  spread. — This  may  be  direct,  in  the  stomach  itself 
or  to  adjacent  organs  immediately  or  through  adhesion  ;  or  indirect, 
by  lymphatics  or  by  blood-vessels. 

Cancer  in  the  stomach  tends  to  spread  along  the  lesser  curvature, 
and,  as  first  pointed  out  by  Rokitansky,  rarely  affects  the  duodenum. 
Although  Brinton  found  the  duodenum  involved  in  10  out  of  125 
cases,  this  high  percentage  has  not  been  borne  out  by  later  observers ; 
thus,  in  131  cases,  Fenwick  found  this  structure  involved  in  2  only. 
However,  as  the  result  of  microscopic  examination  of  63  specimens 


GASTRIC   CARCINOMA  :    DISSEMINATION 


removed  by  operation,  Borrmann  found  the  cnt  edge  of  the  duodenum 
involved  in  20.  On  the  other  band,  carcinoma  of  the  cardiac  end  ol 
the  stomach  frequently  involves  the  oesophagus,  and  vice  versa. 

Growth  extends  in  the  Bubmucosa  early  and  widely;  while  the 
induration  marks  the  limit  of  infiltration  of  the  mucous  membrane, 
the  growth  extends  in  the  submucosa  for  several  centimetres  beyond. 
The  area  of  involvement  of  the  serous  and  muscular  coat  is  always 
Adjacent  organs  may  be  directly  affected,  most  frequently  the 
pancreas,  then  the  liver  and  colon,  rarely  the  Bpleen. 


Fig.  386. — "  Leather  bottle  "  stomach. 

[Royal  College  of  Surgeons  Museum.) 

Adhesions  are  present  in  about  80  per  cent,  of  cases  at  the  time 
of  death,  and  constitute  an  important  method  of  spread. 

Lymphatic  spread. — The  lymphatic  system  of  the  stomach  has 
already  been  described  (p.  300).  In  carcinoma  of  the  pylorus  and 
lesser  curvature  the  lower  coronary  group  of  glands  is  fir*1"  pffc^fd 
Occasionally  a  lymphatic  vessel  runs  past  this  group  of  glands  am! 
terminates  directly  in  one  of  the  upper  coronary  set  ;  this  is  well 
shown  in  Fig.  387,  a  photograph  of  a  portion  of  the  stomach  which 
I  removed.  In  carcinoma  of  this  region  the  subpyloric  glan<  I 
usually  affected,  and  lymphatic  vessels  may  run  directly  to  the  supra- 
pancreatic  glands  and  even  to  the  biliary  chain. 


382 


THE   STOMACH   AND   DUODENUM 


Hey  Groves  has  recently  called  attention  to  the  spread  of  carcinoma 
in  the  great  omentum  in  advanced  cases,  and  has  shown  that  the 
growth  may  be  disseminated  by  adhesion  of  the  great  omentum  to 
neighbouring  organs.  Dobson  and  Jamieson  have  drawn  attention 
to  the  tendency  shown  by  the  glands  associated  with  the  right  gastro- 
epiploic artery  to  ex- 
tend into  the  great 
omentum,  but  there 
are  no  efferent  vessels 
here  that  drain  into 
glands  other  than 
those  of  the  gastro- 
epiploic, subpyloric, 
or  splenic  groups. 

Lymphatic  inva- 
sion is  early  and  con- 
stant^, and present 

in__j3ra£tically  every 
case  at  the  time  of 
operation.  Cuneo 
found  the  glands  of 
the  lesser  curvature 
involved  in  87  per 
cent,  of  cases  exam- 
ined, those  of  the 
greater  curvature  in 
66  per  cent.  Lenge- 
mann,  in  the  exam- 
ination of  20  speci- 
mens removed  by 
operation,  found  that 
the  subpyloric  group 
of  glands  was  in- 
volved in  60  per  cent, 
of  cases,  while  Cuneo 
had  found  them  to 
be  affected  in  2  per 
cent.  only.  Jamieson 
and  Dobson  support 
Lengemann's  observa- 
tions, which  are  in  accord  with  my  own  experience. 

In  a  late  stage  of  the  disease  the  glands  at  the  hilum  of  the  liver, 
those  around  the  cceliac  axis,  the  superior  mesenteric  glands,  the 
biliary  glands,  the  mesocolic  and  the  lumbar  glands  may  be  involved. 


Fig.  387.  —  Portion  of  stomach  removed  at 
operation,  showing  a  lymphatic  vessel  con- 
taining growth  that  runs  directly  to  one  of 
the  upper  group  of  coronary  glands 

{Photograph  taken  from  a  case  oj  the  authors.) 


I) 


GASTRIC   CARCINOMA:    SYMPTOMS 

As  the  "lands  at  t he  hilnni  of  the  liver  merely  receive  vessel*  from 
the  liver  for  transmission  to  the  right  suprapancreatic  and  biliary 
groups,  ami  have  no  vessels  directly  connecting  with  any  gland  group 
receiving  lymphatics  from  the  stomach,  they  must    become  infected 

in  a  retrograde  manner  or  from  a  secondary  growth  in  t lie  liver. 

Henoch,  in  1863,  first  recorded  enlargement  of  the  Left  supra- 
clavicular glands  in  gastric  carcinoma.  An  enlargement  of  these 
glands  is  said  to  take  place  in  3  per  cent,  of  cases.  Involvement  of 
the  right  group  is  a  rare  event. 

Vascular  infection. — This  is  usually  through  the  veins  of  the 
portal  system,  and  produces  secondary  growths  in  the  liver.  It  is 
most  common  in  carcinoma  of  the  body  of  the  stomach  ;  carcinoma 
of  the  pyloric  end  tends  to  affect  the  liver  by  direct  spread.  Rarely, 
the  systemic  veins  disseminate  the  growth,  either  through  direct 
invasion  of  the  inferior  vena  cava,  or  via  the  thoracic  duct  or  liver 

Summary. — Glandular   invasion    is    early    and    almost    invariabl 
while  next  in  order  of  frequency  secondary  deposits  are  found  in  the 
liver,  great  omentum,  and  pancreas. 

Symptoms. — These  will  vary  with  the  situation  of  the  growth. 
In  carcinoma  of  the  pylorus  or  cardiac  orifice,  symptoms  of  obstruc- 
tion appear  early  ;  but  in  carcinoma  of  the  prepyloric  portion  the 
growth  does  not  produce  obstruction  until  late,  and  the  symptoms 
are  therefore  less  marked. 

The  cases  can  be  divided,  according  to  symptoms,  into  three 
groups :  (1)  Following  previous  gastric  disease.  (2)  Occurring  in 
previously  healthy  persons.     (3)  "  Latent." 

1.  This  will  comprise  at  least  50  per  cent,  of  the  cases,  and  in 
many  instances  there  will  be  the  typical  history  of  chronic  gastric 
ulcer — attacks,  at  irregular  intervals,  of  pain  after  food,  relieved,  it 
may  be,  by  vomiting.  It  may  be  noticed  that  in  the  last  attack 
the  pain  is  not  so  readily  relieved  by  rest  or  vomiting,  becomes 
almost  constant,  assumes  a  gnawing  character,  and  wakes  the  patient 
at  night.  There  may  "also  be^aTcTistaste'for  food,  particularly  meat, 
which  was  not  present  in  the  previous  attacks.  In  some  few  cases 
no  change  in  the  character  of  the  symptoms  is  noticed,  but  at  the 
operation  for  supposed  chronic  gastric  ulcer  carcinoma  is  found. 
Occasionally  the  history  is  of  a  gastric  illness,  with  symptoms  of 
ulceration  several  years  before,  followed  by  apparently  perfect 
recovery. 

2.  In  this  group  the  onset  may  be  sudden,  an  acute  hsematemesis 
occurring  in  a  previously  healthy  person,  succeeded  by  a  sense  of 
gastric  discomfort.  In  other  cases  the  symptoms  follow,  according 
to  the  patient,  an  error  in  diet  a  short  time  before.  But  as  a  rule 
the  onset  is  more  gradual.     As  Brinton  wrote  :    "An  elderly  person 


3^4      THE  STOMACH  AND  DUODENUM 

.  .  .  begins  to  suffer  from  a  capricious  appetite  "  ;  a  distaste  for 
food  may  be  first  noticed,  perhaps  a  distaste  for  meat  only.  This 
was  at  one  time  considered  an  important  diagnostic  point,  but  in 
87  cases  in  which  I  made  inquiry  it  was  only  noted  as  the  first 
symptom  in  3,  though  it  is  usually  present  when  the  disease  has 
advanced. 

Pain  is  the  most  constant  feature,  and  is  present  in  85  per  cent, 
of  the  cases.  It  is  not  so  sharp  or  so  localized  as  in  ulcer,  is  often 
not  relieved  when  the  stomach  is  empty,  and  is  seldom  relieved  by  rest. 

Vomiting  may  be  absent  or  infrequent  when  the  growth  is  pre- 
pyloric, and  does  little  to  relieve  the  pain ;  it  frequently  occurs 
independently  of  food,  is  often  offensive,  and  contains  small  quantities 
of  blood.  In  growths  causing  pyloric  obstruction,  vomiting  is  often 
the  first  symptom.  Careful  examination  of  the  vomit  will  show  the 
presence  of  blood  in  practically  every  case.  As  a  rule  it  is  slight,  and 
may  only  be  revealed  by  the  test  for  "  occult  "  haemorrhage  ;  if  greater 
in  amount  it  may  impart  a  ';  coffee-grounds  "  appearance  to  the  vomit. 
Bleeding  sufficient  to  cause  hsematemesis  is  unusual ;  Brinton  esti- 
mated its  frequency  as  6  per  cent.  Fatal  haemorrhage  occurs  in  not 
more  than  1  per  cent,  of  the  cases. 

When  the  growth  is  diffuse,  involving  the  whole  of  the  stomach 
("  leather-bottle  "  stomach),  there  is  inability  to  take  more  than  a 
certain  amount  of  food  without  causing  vomiting,  and  the  amount 
that  can  be  taken  gradually  diminishes. 

A  palpable  tumour  is  present  at  some  time  during  the  course  of 
over  70  per  cent,  of  the  cases  ;  but  it  must  be  remembered  that  it 
is  a  late  sign.  It  has  been  stated  (Czerny,  Bindfleisch)  that  the 
presence  of  a  tumour  means  that  the  disease  is  inoperable.  This  is 
not  so.  Instances  have  been  recorded,  among  others  by  Mayo  Robson 
and  Kocher,  of  patients  alive  and  well  six  or  seven  years  after  partial 
gastrectomy  for  carcinoma,  although  a  tumour  had  been  palpable 
before  operation.  While  the  majority  of  tumours  are  felt  in  tin- 
umbilical  region,  a  tumour  due  to  carcinoma  of  the  pylorus  may  be 
found  in  almost  any  part  of  the  abdomen,  while  those  due  to  growths 
of  the  lesser  curvature  and  to  "  leather-bottle  "  stomach  are  seen 
in  the  epigastric  and  left  hypochondriac  regions. 

Inspection  of  the  abdomen  will  generally  reveal  the  tumour  mo\  in- 
on  respiration.  Tumours  of  the  pylorus  can  be  usually  moved  from 
side  to  side,  and  vary  in  the  position  they  occupy  according  to  the 
condition  of  the  stomach.  Many  of  these  tumours  receive  trans- 
mitted pulsation  from  the  aorta.  Very  rarely  indeed  the  patient 
comes  under  observation  because  the  tumour  has  been  noticed  and 
no  other  signs  are  present.  Inflation  of  the  stomach  will  sometimes 
aid  the  diagnosis  in  obscure  cases. 


GASTRIC    CARCINOMA:    SYMPTOMS 

In  pointed  <>ut  by  Wickham  Legg  in   L880 

■n  at  the  umbilicus. 

Anaemia,  loss  "t  weight,  and  change  in  gastric  secretion 
Bymptoms  to  be  found  in  all  late  cases. 

Anaemia  i-  present  in  all  advanced  cases;  in  a  few  the  resemblance 
of  the  symptoms  to  those  of  pernicious  ana mia  lias  led  to  error  of 
diagnosis  and  treatment,  hut  examination  of  the  blood  will  prevent 
this  mistake.  The  blood-changes  in  carcinoma  of  the  stomach  are 
those  of  a  secondary  ana  mia.  The  red  corpuscles  are  rarelv  reduced 
lower  than  3,000,000,  the  average  oi  59  cases  recorded  by  Osier  and 
•3  being  3,712,186.  There  is  a  slight  leucocytosis  in  most  cases. 
It  has  been  stated  by  Muller  that  digestive  leucocytosis  is  absent  in 
carcinoma  of  the  stomach.  Very  little  reliance  can  be  placed  on  this 
tor  it  is  present  in  nearly  half  the  -jammed   (Osier  and 

McCrae,  Fenwick). 

Progressive  loss  of  weight  may  very  rarelv  be  the  first  rign  of 
•.     Thus,  in  one  patient  under  my  care,  a  man  of  57,  progi 
weight,  from  16  st.  3  lb.  to  12  st.  6  lb.,  was  noticed  for  twelve 
m«»nths  before  the  onset  of  any  gastric  symptom. 

Changes  in  gastric  secretion  are    present    in   the    late    s 
of  the  disease.     Golding  Bird,  in   1843,  pointed  out    that   free  HC1 

bsent  in  cases  of  cancer  of  the  stomach.  Among  495 
published  by  various  authors,  free  HO  was  absent  in  89  per  cent. 
(Fenwick).  It  has  been  stated  that  free  HC1  is  only  present  in  those 
cases  which  originate  from  ulcer  ;  it  is  certainly  usually  present  in 
patients  with  a  previous  history  of  long-standing  gastric  trouble,  and 
absent  in  those  in  whom  the  carcinoma  develops  without  previous 
history  of  gastric  disease.  It  is  a  test  on  which  too  much  stress  should 
not  be  laid,  for  it  is  a  late  sign  and  due  to  concomitant  chronic  gastritis. 
Hammerschlag,  from  the  examination  of  mucosa  removed  from  the 
stomach  in  cases  of  gastrojejunostomy,  found  that  when  free  11'  I 
bsent  the  specific  glandular  elements  had  disappeared  and  been 
replaced  by  cylindrical  epithelium. 

Free  HC1  may  be  present  throughout  the  whole  course  of  the 
disease,  and  it  may  be  absent  from  the  gastric  juice  in  patients  with 
carcinoma  of  other  organs  (Mansell-Moullin.  Moore,  Palmer).  This 
statement  is  disputed  by  Willcox,  who  has  found  free  HC1  present 
in  the  gastric  contents  of  patients  with  carcinoma  of  organs  eve;: 
contiguous  to  the  stomach.  This  is  in  agreement  with  my  own 
experience.  It  has  been  stated  (Seidelin)  that  free  HC1  is  absent  in 
40  per  cent,  of  people  over  the  age  of  50. 

Fragments  of  growth,  blood,  sarcince.  and  the  Oppler-Boas  bacil- 
lus may  be  found  on  microscopical  examination  of  the  vomit  (p.  311). 
Salomon  has  stated  that  the  presence  of  nucleo-albumin  and  mucin. 


386  THE   STOMACH   AND    DUODENUM 

tested  by  Esbacli's  reagent,  in  the  washings  of  a  fasting  stomach  is 
in  favour  of  carcinoma.     These  are  also  late  signs. 

3.  As  already  pointed  out,  malignant  disease  of  the  stomach  may 
be  latent,  progressive  loss  of  weight  perhaps  being  the  first  sign  of  its 
presence.  In  other  cases,  ascites  or  a  tumour  due  to  secondary  growth 
is  first  noticed.  $» 

Fenwick  was  able  to  collect  from  the  records  of  the  London 
Hospital,  during  the  twenty  years  preceding  1902,  14  cases  in  which 
"  the  presence  of  ascites  constituted  the  sole  indication  of  cancer 
of  the  stomach."  In  at  least  half  of  these  there  was  no  evidence  to 
connect  the  ascites  with  a  malignant  growth  of  the  stomach. 

Cases  with  ascites  fall  into  two  groups — (a)  those  in  which  the 
ascites  is  the  first  symptom  seriously  to  attract  the  patient's  attention, 
and  (b)  those  in  which,  following  indefinite  abdominal  symptoms, 
there  is  a  sudden  onset  of  acute  pain  and  swelling.  Four  cases  have 
been  under  my  care  ;  in  all  the  ascites  had  been  preceded  by  vague 
abdominal  symptoms  of  which  no  notice  was  taken,  in  2  the  onset 
of  ascites  was  gradual,  in  2  so  acute  that  the  diagnosis  of  a  perforative 
lesion  was  made. 

In  cases  in  which  metastases  call  attention  to  the  disease  the 
secondary  growths  are  usually  in  the  liver  ;  but  a  malignant  ovarian 
tumour  may  be  the  first  sign  for  which  the  patient  comes  under 
observation. 

Perforation  may  be  acute  or  subacute.  Acute  perforation  takes 
place  in  about  3  per  cent,  of  cases,  but  occasionally  a  subacute  per- 
foration with  the  formation  of  a  perigastric  abscess  occurs.  One 
example  of  each  was  present  in  87  cases  under  my  care. 

Fistulae  may  open  externally  or  into  the  colon,  rarely  into  the 
duodenum  (see  p.  402). 

Thrombosis  of  veins  may  occur  in  the  late  stage.  Trousseau 
wrote  :  "  Should  you,  when  in  doubt  as  to  the  nature  of  an  affection 
of  the  stomach,  observe  a  vein  becoming  inflamed  in  the  arm  or  leg, 
you  may  dispel  your  doubt  and  pronounce  in  a  positive  manner  that 
there  is  a  cancer." 

Fever  is  present  in  nearly  a  third  of  the  cases  at  some  period 
during  the  course. 

Jaundice  is  stated  to  occur  in  13  per  cent,  of  cases  (Fenwick), 
and  is  usually  due  to  extension  of  the  growth  to  the  head  of  the 
pancreas. 

Diagnosis. — At  the  present  time  a  certain  diagnosis  at  the  most 
favourable  period  for  removal  is  impossible.  All  the  signs  which 
make  for  a  positive  diagnosis  are  late  signs. 

Help  may  be  expected  in  the  future  from  the  use  of  the  gastro- 
scope,  and  it  may  be  that  examination  of  the  blood  will  be  of  service. 


GASTRIC  CARCINOMA:    DIAGNOSIS  387 

Kelling,  Crile,  and  others  bave  attempted  the  early  diagnosis  by  m< 
oi  .1  bsemolytic  test.  Wideroe,  Crile,  and  Pans  found  a  positive  reac- 
tion in  over  60  per  cent,  of  the  cases.  All  the  patients  with  malignanl 
disease  who  failed  to  give  a  positive  reaction  had  advanced  disea 
ES.  C  Hort  has  shown  that  the  power  of  inhibiting  tryptic  digestion 
is  much  greater  in  the  serum  of  patients  Buffering  from  carcinoma; 
bu1  as  the  antitryptic  index  is  raised  in  many  other  diseases  it  is 
ohiefly  helpful  from  its  negative  side,  although  in  Hort's  cases  the 
test  was  of  no  value  in  G  out  of  100.  It  is  suggested  that  absence  of 
a  rise  in  the  antitryptic  index  of  the  serum  may  be  of  value  in  the 
diagnosis  of  chronic  gastric  ulcer  from  carcinoma.  Unfortunately, 
neither  of  these  tests  is  sufficiently  reliable  to  help  materially  with 
the  diagnosis.  It  can  only  be  laid  down  that  surgical  treatment 
should  be  considered  in  all  cases  in  which  digestive  symptoms  in  an 
adult  fail  to  respond  to  thorough  meidcal  treatment,  or  relapse,  and  that 
exploration  should  be  undertaken  in  all  cases  in  which  the  disease  is 
due  to  some  structural  alteration  in  the  stomach. 

A  careful  examination  of  the  gastric  contents  should  be  made. 
Absence  of  free  HC1,  diminution  of  the  total  acidity,  as  well  as  the 
presence  of  lactic  acid  and  the  Oppler-Boas  bacillus,  are  signs 
suggestive  of  carcinoma. 

In  patients  in  whom  carcinoma  originates  in  a  previously  healthy 
stomach,  free  HC1  is  usually  absent  and  the  total  acidity  is  low  by 
the  time  they  come  under  observation.  Whether  this  obtains  within 
a  fewr  weeks  of  the  onset  of  the  symptoms  remains  for  further 
investigation. 

When  the  malignant  growth  supervenes  on  a  chronic  gastric  ulcer, 
free  HC1  is  usually  present  in  about  normal  amount,  and  the  total 
acidity  corresponds.  These  are  the  cases  in  wThich  diagnostic  help 
is  so  much  needed  ;  no  information  of  any  value  is  given.  Again, 
in  cases  of  chronic  gastritis  of  long  duration  and  in  certain  cases 
of  chronic  ulcer  and  after  severe  haemorrhage,  free  HC1  may  be 
absent. 

It  is  evident  that  too  much  reliance  must  not  be  placed  upon  the 
result  of  gastric  analysis,  but,  taken  writh  other  symptoms,  it  is  parti- 
cularly helpful  in  those  cases  in  w7hich  gastric  symptoms  appear  for 
the  first  time  in  adults. 

The  vomit  and  faeces  should  also  be  examined  for  occult  blood. 

All  are  agreed  that  exploration  should  be  undertaken  when  any 
suspicion  of  cancer  exists,  without  waiting  for  the  diagnosis  to  be 
made  certain. 

When  a  tumour  is  present  it  must  be  diagnosed  from  tumour  of 
the  gall-bladder  and  colon  ;  if  other  means  have  failed,  distension  of 
the  stomach  with  air  will  in  most  cases  enable  this  to  be  done. 


388  THE    STOMACH    AND    DUODENUM 

Even  when  the  abdomen  has  been  opened  and  the  stomach  exposed 
it  may  be  impossible  to  make  the  diagnosis  of  malignancy  without 
microscopical  examination.  It  is  in  these  cases  that  the  result  of  a  pre- 
vious chemical  examination  of  the  gastric  contents  after  a  test  meal 
may  be  invaluable.  In  recorded  cases  the  condition  has  been  diagnosed 
at  the  operation  as  carcinoma  and  treated  by  partial  gastrectomy, 
yet  subsequent  microscopic  examination  has  revealed  chronic  ulcer 
only,  and  a  supposed  palliative  operation  has  led  to  complete  dis- 
appearance of  the  tumour  and  proved  to  be  curative.  Points  to  be 
considered  are  the  appearance  and  feel  of  the  tumour,  its  method  of 
spread,  and  affection  of  lymphatic  glands.  In  carcinoma  of  the 
stomach  the  peritoneum  is  usually  thickened  and  opaque,  small  out- 
lying patches  of  the  same  nature  are  seen,  and  the  lymphatics  are 
often  marked  out.  The  shaggy,  red-stippled  appearance  of  the  peri- 
toneum, and  the  thickening  -with  a  depressed  centre,  seen  in  chronic 
gastric  ulcer,  are  rarely  present.  On  palpation,  distinct  irregular 
induration  may  be  felt.  If  there  is  doubt  a  portion  of  the  suspected 
growth  should  be  removed  and  submitted  to  rapid  microscopical 
examination.  Even  in  this  way  it  may  be  impossible  to  make  a 
definite  diagnosis. 

Treatment. — The  treatment  of  suspected  carcinoma  is  surgical ; 
if  the  question  that  a  growth  is  present  is  raised,  valuable  time  should 
not  be  wasted.  In  the  words  of  Hale  "White  :  "If  symptoms  of  serious 
chronic  indigestion  first  appear  after  the  age  of  40,  organic  disease  of 
the  stomach  should  be  strongly  suspected,  and,  if  a  comparatively 
short  period  of  medical  treatment  does  not  effect  a  cure,  it  may  be 
quite  justifiable  to  open  the  abdomen. "  Were  his  advice  carried  into 
effect,  many  patients  would  be  operated  upon  in  the  precancerous  stage, 
the  percentage  of  cases  found  suitable  for  radical  treatment  increased, 
and  the  ultimate  results  rendered  more  favourable  than  they  are  at 
present.  The  percentage  of  cases  suitable  for  resection  must  vary  in 
every  clinic,  and  will  become  greater  as  time  goes  on.  As  an  average 
the  following  may  be  given  :  In  rnv  series  of  87  cases,  21  were  treated 
by  excision  ;  these  figures  almost  correspond  with  those  given  by 
Poncet,  Delore  and  Leriche  (in  137  cases  operated  upon  excision  was 
performed  in  40),  and  with  those  from  the  Breslau  clinic  given  by 
Kiittner  (102  excisions  in  366  cases  of  carcinoma). 

Operation  should  be  undertaken  in  all  cases  of  suspected  or  proved 
carcinoma  of  the  stomach,  unless  obviously  inoperable  by  reason  of 
secondary  growths,  the  surgeon  being  prepared  to  do  a  partial  or 
a  complete  gastrectomy. 

The  surgical  treatment  can  be  summed  up  shortly  :  the  operation 
of  choice  is  partial  gastrectomy  ;  in  certain  cases  total  gastrectomy 
may  be  necessary.     Simple  gastrojejunostomy  should  only  he  •performed 


GASTRIC  CARCINOMA:    TREATMENT  3*9 

when  the  growth  is  producing  pyloric  obstruction  :  in  other  cases  no  good 
results.  If  cardiac  obstruction  is  present,  gastrostomy  may  be  done; 
in  certain  cases  jejunostomy  may  be  advisable. 

The  incision  should  be  made  through  tin-  rigb.1  rectus  muscle  or 
in  the  middle  line,  and  the  stomach  examined.  The  question  oi 
malignancy  must  first  be  settled.  If  doubl  exists,  a  portion  of  the 
ulcer  or  a  eland  is  removed  and  examined  microscopically  while  a 
gastrojejunostomy  suitable  for  use  after  partial  gastrectomy  is  being 
performed,  it'  a  rapid  microscopic  examination  cannot  be  obtained 
the  abdomen  should  be  closed,  and  a  second  operation  undertaken 
at  a  later  date  if  the  section  reveals  malignancy  or  the  progress  of 
the  case  renders  the  diagnosis  certain.  If  the  suspected  carcinoma 
is  situated  on  the  lesser  curvature  the  absence  of  relief  as  the  result 
of  the  gastrojejunostomy  will  clinch  the  diagnosis. 

If  the  growth  is  obviously  malignant  its  operability  must  be  settled. 
The  decision  depends  upon  the  presence  and  degree  of  adhesions  and 
infiltration  of  other  structures,  particularly  the  liver  and  pancreas, 
of  massive  glandular  enlargements,  and  of  secondary  deposits  in  the 
peritoneum  or  at  a  distance.  In  every  case  a  careful  examination 
should  be  made  before  this  question  is  decided.  If  from  the  presence 
of  adhesions  it  is  impossible  to  make  out  the  nature  of  any  tumour 
present,  gastrojejunostomy  should  be  performed,  and  a  further  opera- 
tion undertaken  after  the  lapse  of  a  fortnight.  If  the  mass  has  been 
due  to  chronic  ulcer,  great  improvement  will  have  taken  place  ;  in  all 
probability  the  tumour  will  have  almost  completely  disappeared,  or, 
even  if  it  be  carcinomatous,  the  subsidence  of  the  coincident  inflam- 
matory swelling  will  have  made  operation  easier. 

The  death-rate  of  simple  exploration  without  further  interference 
is  small ;  Mayo  Robson  estimates  it  at  from  3  to  5  per  cent. 
Among  39  personal  cases,  1  died  the  following  day — a  patient  in 
whom  the  disease  was  very  advanced  and  operation  was  undertaken 
to  attempt  to  give  some  relief  to  the  incessant  vomiting,  but  his 
condition  was  so  bad  that  even  jejunostomy  was  thought  in- 
advisable. 

Occasionally  after  an  exploratory  operation  a  period  of  improve- 
ment sets  in  and  all  symptoms  disappear,  for  a  time  raising  a  doubt 
as  to  the  correctness  of  the  diagnosis.     Three  such  cases  have  been 

under  my  care. 

* 
A  man  of  48  who  had  had  symptoms  for  eight  weeks  was  explored  in 
October,  1903,  a  large  malignant  growth  on  the  lesser  curvature  being  found. 
He  left  hospital  a  month  later,  feeling  quite  well.  All  symptoms  were  in 
abeyance  for  fourteen  months  ;  they  then  returned,  and  he  died  in  hospital 
in  March,  1905,  the  diagnosis  being  confirmed  at  autopsy.  A  case  has  been 
recorded  by  Keen  and  Stewart  in  which  symptoms  were  in  abeyance  for 
seventeen  months  after  exploration. 


390  THE   STOMACH   AND   DUODENUM 

When  possible,  partial  gastrectomy  should  be  carried  out  (p.  404). 
In  a  few  cases  it  may  be  justifiable  to  excise  at  the  same  time  a  portion 
of  the  liver  where  the  pylorus  has  become  adherent  to  it,  or  where 
the  growth  has  directly  attacked  it,  or  a  portion  of  the  transverse 
colon  where  this  is  involved. 

Total  gastrectomy  is  rarely  necessary  except  in  cases  of  diffuse 
growth — "  leather-bottle  "  stomach. 

With  regard  to  the  immediate  mortality  :  Deaver  and  Ashurst 
collected  747  cases  of  partial  gastrectomy  with  an  immediate  mortality 
of  a  little  over  25  per  cent.  This  may  be  taken  as  about  the  average 
immediate  mortality  at  the  present  time,  although  individual  surgeons 
have  obtained  better  results — thus,  the  Mayos'  226  cases  with  12'4 
per  cent,  deaths  ;  Maydl,  16  per  cent.  ;  Mayo  Eobson,  13  per  cent. 

Of  my  21  cases  of  partial  gastrectomy  3  died  as  the  result  of  operation  ; 
1,  in  whom  I  excised  a  wedge-shaped  portion  of  the  liver,  two  months 
later  with  a  biliary  fistula  ;  another  died  of  shock  within  twenty-four  hours. 
In  the  other  case  the  wound  was  sutured  hurriedly  with  through-and-through 
stitches  on  account  of  the  patient's  condition,  but  these  gave  way  on  the 
fourth  day,  and  he  died  of  broncho-pneumonia  five  days  after  the  second 
anaesthetic.  Patients  are  alive  without  recurrence  twenty-seven  months, 
twenty-two  months,  twenty  months,  twelve  months,  eleven  months,  six 
months,  and  four  months  after  operation.  Of  those  in  whom  recurrence 
took  place,  the  earliest  was  at  three  months,  the  latest  at  thirty  months. 

In  127  cases  analysed  by  Hey  Groves  in  which  the  cause  of  death 
was  given,  peritonitis  accounted  for  78,  shock  23,  lung  complications  20. 

With  improved  methods  of  operating,  the  death-rate  should  cer- 
tainly be  no  more  than  15  per  cent. 

As  to  the  after-results,  cases  have  been  recorded  well  fourteen 
years  (Braun),  thirteen  years,  twelve  years  (Lemoin),  eleven  and  a 
half  years  (Maydl),  eight  years  (Goldschwend),  five  years  and  ten 
months  (Poncet)  after  operation. 

The  average  duration  of  life  after  partial  gastrectomy  in  cases 
in  which  recurrence  takes  place  is  about  eighteen  months.  The  quality 
of  the  life  is  good,  and  death  occurs  less  painfully.  Recurrence  is 
rare  after  two  years  ;  if  life  is  prolonged  beyond  four  years,  there  is 
a  good  prospect  of  cure.  From  the  collected  statistics  of  Paterson, 
15  per  cent,  of  the  number  operated  upon  lived  five  years  or  more. 
In  140  resections  of  stomach  for  carcinoma  recorded  by  Kocher  (1910), 
20  per  cent,  remained  well  for  over  four  years. 

At  the  present  time  it  is  safe  to  say  that  the  general  operative 
mortality  is  about  25  per  cent. ;  of  the  75  per  cent,  who  recover,  60  per 
cent,  will  succumb  to  the  disease  within  three  years,  after  a  period 
of  comparative  comfort,  and  15  will  survive  over  five  years  and 
may  possibly  be  cured.  These  figures  will  show  great  improvement 
in  the  future. 


GASTRIC   CARCINOMA:    TREATMENT  l  n 

The  death-rate  of  total  gastrectomy  appears  to  be  aboul   40  pet 

cent.  :  in  l'7  cases  collected  by  Paterson  it  was  36  per  cent.  The 
average  duration  of  life  in  those'  in  which  recurrence  took  place  was 
nineteen  months;  17  per  cent,  were  free  from  symptoms  five  years 
after  operation;  1  was  well  at  eight,  and  1  at  seven  years  after 
operation. 

Gastrojejunostomy  should  be  performed  for  the  relief  of  symptoms 
when  pyloric  obstruction  is  present.     The  death-rate  in  these  ca 
is    considerably  higher   than   when   the   operation  is  performed   for 
simple  diseases. 

Poncet,  Delore  and  Leriehe  have  recorded  87  cases  with  33  per  cent. 
death-rate:  Kindl.  21  per  cent.  ;  Moynihan,  35  cases,  14  percent,  death-rate; 
Sherren,  ~2~  eases,  5  deaths. 

With  regard  to  the  duration  of  life  :  this  cannot  be  predicted. 
The  average  appears  to  be  about  six  months,  but  the  operation  must 
be  done  only  in  the  cases  stated.  The  longest  duration  hi  my  cases 
was  two  years,  with  absolute  comfort  for  twenty-two  months ;  another 
lived  fifteen  months,  with  comfort  for  thirteen  ;  a  third  nine  months, 
with  comfort  for  eight ;  whilst  in  the  others  death  took  place  within 
six  months;  but  the  relief  afforded  by  the  operation  in  all  made  it 
worth  doing.  Unless  the  growth  is  causing  pyloric  obstruction,  relief 
of  symptoms  is  not  obtained. 

The  radical  treatment  of  carcinoma  of  the  cardiac  end  of  the 
stomach  is  at  present  in  the  experimental  stage.  The  researches  of 
Sauerbruch,  Willy  Meyer,  Janeway  and  Green,  Meltzer  and  Auer, 
Brauer,  and  others  have  raised  hope  that  it  may  be  possible  to 
extend  operative  interference  to  this  portion  of  the  stomach.  Three 
cases  have  been  recorded  in  which  operation  was  carried  out,  the 
growth  being  removed  and  cesophago-gastrostomy  done  (Wendel, 
Wiener,  Janeway  and  Green) :  death  occurred  from  secondary 
hemorrhage  in  the  first  case,  in  the  second  from  subphrenic  abscess 
twelve  days  after  operation  ;  and  the  third  died  fifty-four  hours  later 
with  an  empyema. 

Gastrostomy  should  be  performed  when  it  becomes  impossible  to 
take  food.  The  immediate  mortality  is  not  high,  and  an  interval  of 
comfort  of  from  three  to  six  months,  in  some  cases  as  long  as  eighteen, 
is  given. 

Jejunostomy  is  an  operation  rarely  advisable  for  carcinoma  of 
the  stomach,  though  it  may  be  performed  to  obtain  relief  from  pain 
and  vomiting.  Patients  seldom  survive  operation  longer  than  a 
few  weeks.  The  immediate  mortality  in  127  cases  of  jejunostomy 
collected  by  Billon  was  29  per  cent.,  and  the  majority  of  patients 
succumbed  under  two  months  ;   only  one  lived  for  a  year. 


392  THE   STOMACH   AND   DUODENUM 

CARCINOMA   OF    THE   DUODENUM 

Carcinoma  of  the  duodenum  is  rare.  Maydl  and  Schlesinger  found  thai 
it  represented  2  per  cent,  of  the  primary  malignant  growths  of  intestine 
Fenwick  states  its  comparative  frequency  as  compared  with  carcinoma 
of  the  stomach  as  1  to  20  ;  but  if  anything  this  over-states  the  frequency. 

It  is  more  common  in  men  than  in  women  (Fenwick,  37  men,  14  women), 
and  is  most  common  between  the  ages  of  40  and  50.  It  may  originate  in 
a  chronic  ulcer ;  according  to  Fenwick,  at  least  10  instances  have  been 
recorded.  In  3  cases  observed  by  Mayo,  in  one  certainly  and  in  another 
probably,  it  had  its  origin  in  this  manner  ;  the  third  case  was  too  far  advanced 
to  enable  any  opinion  to  be  given.  In  some  cases  it  has  been  associated  with 
gall-stones. 

It  most  frequently  arises  in  the  second  part  of  the  duodenum.    In  41 
collected  by  Rolleston,  24  had  their  origin  here,  8  in  the  first  part ;  while  in 
51  collected  by  Fenwick,  29  were  in  the  second  part,  11  in  the  first,  7  in  the 
third.    It  may  be  secondary  to  carcinoma  of  the  pancreas,  of  the  gall-bladder 
or  bile-ducts. 

The  growth  is  usually  cylindrical-celled,  and  has  a  constricting 
effect,  like  a  similar  growth  elsew'here.  When  composed  of  spheroidal 
cells  it  forms  a  soft,  flat  mass  or  a  deep  fungating  ulcer.  Colloid 
degeneration  may  occur. 

Symptoms. — These  vary  with  the  portion  of  the  duodenum 
involved. 

1.  In  the  supra-ampullary  variety  the  symptoms  resemble  pyloric 
carcinoma  and  may  very  rarely  follow  those  of  chronic  ulcer.  Diag- 
nosis from  pyloric  carcinoma  is  impossible.  A  fixed  or  only  slightly 
mobile  tumour  can  usually  be  felt  in  the  right  hvpochondrium. 

2.  Carcinoma  in  the  peri-ampullary  portion  most  often  arises  in 
the  mucous  membrane  covering  the  biliary  papilla.  Usually,  owing 
to  the  involvement  of  the  papilla,  jaundice  is  present  (in  23  out  of 
25  of  Mathieu's  cases)  ;  it  is  often  intermittent,  thus  differing  from 
that  due  to  carcinoma  of  the  head  of  the  pancreas  or  of  the  common 
bile-duct. 

Painless  jaundice  is  usually  the  first  symptom,  and  is  followed 
by  gastric  symptoms  due  to  dilatation.  The  gall-bladder  is  usually 
distended,  and  occasionally  a  fixed  tumour  can  be  felt  in  the  right 
hypochondrium  near  the  middle  line.     (Plate  90.) 

Not  infrequently  infection  and  suppurative  cholangitis  occurs. 

3.  In  the  infra-ampullary  cases  the  stomach  and  duodenum 
are  dilated,  and  the  symptoms  resemble  those  of  pyloric  obstruction, 
but  with  one  important  difference,  viz.  that  the  vomit  always  contains 
bile  and  pancreatic  juice.  The  latter  can  be  demonstrated  by  the 
digestion  of  fibrin  after  a  few  grains  of  sodium  bicarbonate  have 
been  added  to  the  filtered  vomit.  Intermittent  attacks  of  intestinal 
obstruction  are  also  common. 


Gall  bl 


.Stomach 


Dilated 
pancreatic 
,  "  duct 


Carcinoma  of  second  part  of  the  duodenum. 

(Pathological  Institute,  London  Hospital.) 


PLATE  90. 


DUODEN  \l     CARCINOMA 

Prognosis.  The  average  duration  oi  life  is  about  seven  months 
(Fenwick).  Haemorrhage,  perforation,  abscess,  '•Mcin.il  or  internal 
fistula,  may  complicate  the  course  of  the  diseai 

Treatment.  —  Palliative  treatment  is  frequently  all  thai  is 
possible.  In  most  cases  this  will  consist  in  gastrojejunostomy,  but, 
when  obstructive  jaundice  is  present,  relief  may  be  obtained  by  chole- 
cystenterostomy.  When  the  growth  involves  the  first  portion  of  ihc 
duodenum,  removal,  together  with  the  adjacent  portion  of  stomach, 
Bubpyloric  and  right  gastro-epiploic  glands,  should  be  carried  out. 
Carcinoma  of  the  third  part  of  the  duodenum  has  been  successfully 
removed  by  Syme.     Hitherto,  operations  for  malignant  growth  of  the 

■  ml  portion  of  the  duodenum  have  been  palliative  only,  the  growth 
being  locally  excised  and  the  common  bile-duct  re-implanted.  I 
have  been  recorded — by  Korte,  in  which  the  patient  was  alive  nearly 
four  years  after  the  operation;  by  Deaver,  in  which  the  patient  was 
alive  and  well  <>ne  year  after  operation  ;  and  by  Czerny,  Halsted.  and 
W.  J.  Mayo,  in  which  the  patient  died  a  few  days  after  operation. 
Radical  operation  in  this  situation  will  always  necessitate  removal 
of  a  portion  of  the  pancreas  in  addition  to  the  duodenum.  The 
duodenum  and  head  of  the  pancreas  were  first  removed  by  Codivilla 
in  1-  -.  j  stro-jejunostomy  and  cholecystenterostomy  being  per- 
formed, and  the  patient  dying  twenty-four  days  later. 

Attention  has  again  been  directed  to  this  possibility  by  the  recent 
work  of  French  surgeons.  Desjardins,  in  1907,  and  Sauve,  in  1908, 
pubbshed  suggested  methods  of  operation,  which,  however,  had  the 
same  failing,  that  they  were  operations  intended  to  be  completed  in 
one  stage.  As  patients  with  obstructive  jaundice  stand  prolonged 
operative  procedures  badly,  Kausch.  in  1909,  devised  and  carried  out 
successfully  a  two-stage  operation  which  is  an  advance  in  the  surgery 
of  this  region.  At  the  first  operation  the  gall-bladder  was  united  to 
the  jejunum  and  entero-anastomosis  done  below.  At  the  second 
operation,  performed  after  disappearance  of  the  jaundice,  a  posterior 
gastroenterostomy  was  made,  the  pylorus  divided  and  closed,  and 
the  descending  portion  of  duodenum  removed.  The  common  bile-dint 
was  ligatured  after  as  much  as  necessary  had  been  removed,  a  portion 
of  the  head  of  the  pancreas  excised,  and  the  lower  duodenal  end  then 
drawn  over  the  stump.    The  case  was  reported  a  month  after  operation. 

SARCOMA    OF    THE    STOMACH 

Sarcoma  of  the  stomach  is  a  comparatively  rare  disease.     It  was 
recorded    by  Sibley  in    1816  ;   Schlesintrer,  in  1897  was  able   to  collev 
jes  :  Howard,  in  1902.  61  cases;  Ziesche  and  Davidsohn,  in  1900, 150  cases. 

It  may  occur  at  any  age,  but  is  most  common  between  the  ages 
and   50.     Tie  re   equally   affected,    except    in   fibro-sarcoma,   which 

is  more  common  in  women. 


394  THE   STOMACH   AND   DUODENUM 

Fenwick  estimated  that  sarcomas  constitute  from  3  to  8  per  cent, 
of  all  tumours  of  the  stomach. 

The  growth  may  be  composed  of  round  or  spindle  cells,  and  the 
intercellular  substance  may  be  very  scanty,  or  it  may  be  definitely 
fibrous.  Myomatous,  myxomatous,  or  angiomatous  tissue  may  be 
found  in  any  given  c 

The  round-celled  sarcoma  La  the  most  fommon  type  (60  per  cent.), 
spindle-celled  the  next  (36  per  cent.). 

Four  types  can  be  recognized :  (1)  Round-celled  sarcoma.  ('!) 
Spindle-celled  sarcoma.  (3)  Lympho-sarcoma.  (4)  Secondary  to  Bar- 
coma  of  retroperitoneal  glands. 

1.  Round-vetted  sarcoma  commences  in  the  submucous  tissue,  and 

may  be  diffuse  or  may 
form  a  circumscribed  tu- 
mour projecting  into  the 
lumen  of  the  stomach. 
It     occurs     most    com- 


.-->-  *V..^- .*>':    '•»     1  monly    in     the     pyloric 

•V*)?^'/^  *.  » m/m  region     and    along    the 

^r*>-  ,u,-"««.,;«»     3#«  %     I     -\  crreater    curvature,     but 

s»   ji<  fe*  <£■*&  >T«~<5»*A  %   V-"  -<  "\\*  rarely  gives  rise  to   py 

9  *►       ^©  $    r  ~^~\  ',   m^jm        -  loric    obstruction.      Th 


The 
>  e.^«>  y  '^ee^ "   ■  y  a      ^  whole     organ     may    be 

.rt^{      '  -.  £&V^JL*        affected.    Metastases  are 

<^-Y     ^         ^  *i         ~*  "        o"      ;      commonly  present. 
Fig.  388. — Lympho-sarcoma  (Kundrath's  type).  2.  Spindle-celled    sar- 

(.w™**,  /v„r.  „/  m.  s^.)  comas,    fibro  -  sarcomas, 

myo-sareomas  or  endo- 
thehomas  usually  form  circumscribed  tumours  springing  from  the 
greater  curvature,  and  presenting  a  polypoid  mass.  They  are  all 
liable  to  myxomatous  change  and  cyst -formation.  They  tend  to 
project  towards  the  serous  coat,  and  may  fill  the  greater  part  of 
the  abdominal  cavity. 

3.  Lymphosarcomas  are  composed  of  lymphoid  cells  in  a  fibrillar 
meshwork  (Kundrath,  see  Fig.  388).  Originating  in  a  lymph  follicle 
of  mucous  membrane,  or  a  lymphatic  gland  in  the  pharynx  or  any 
part  of  the  intestinal  tract,  they  may  spread  along  the  wall  of 
these  tubes  and  bring  about  dilatation  of  the  lumen.  In  some  cases 
polypoid  submucous  growths  are  present. 

In  the  stomach  they  originate  in  the  submucous  tissue,  and  may 
spread  throughout  the  intestinal  tract,  thus  differing  from  round- 
celled  sarcoma,  which  is  confined  to  the  stomach. 

The  growth,  although  commencing  in  the  submucous  tissue,  infil- 
trates all  the  coats  of  the  stomach  and  thus  causes  marked  increase 


GASTRIC   SARCOMA 


395 


in  thickness  of  the  wall ;  in  the  case  described  bySalaman  it  measured 

at  one  place  lh  in.     According  to  Salaman.  I'J.  cases  of  this  nature 
("■'•II  recorded.    Some  of  these  tumours    have   been    described 
as   lymphadenomas   of    stomach,   a    condition    which,    if    it  occurs 
at  all,  is  very  care. 

•4.  Secondary  to  retroperitoneal  (/lands. — The  intestinal  tract  is  never, 
oi  rarely  affected  in  true  lymphadenoma.  It  is  well  known  that, 
in  lymphadenoma  in  other  parts  of  the  body,  glands  which  for  years 
have  been  clinically  "  lymphadenomatous  "  may  coalesce  and  infiltrate 


Fig.  389. — Secondary  involvement  of  stomach  in  "  lymph- 
adenoma." 

(Salamaii,  Proc.  of  Path.  Sac.) 

the  surrounding  tissues.  It  is  probable  that  the  cases  in  which  the 
stomach  is  involved  secondarily  to  neighbouring  glands  are  instances 
of  this  nature  (Fig.  389).  Many  groups  of  glands  and  the  tonsils  are 
usually  involved.  Salaman  collected  8  cases  and  suggested  the  name 
lymphadeno-sarcoma  for  these  growths. 

Symptoms. — The  symptoms  of  round-celled  sarcoma  resemble 
those  of  carcinoma  of  the  stomach.  A  tumour  is  present  in  about 
30  per  cent,  of  these  cases.  Haemorrhage  is  rare.  Secondary  deposits 
in  the  skin  arc  not  uncommon. 


yjS  THE   STOMACH   AND   DUODENUM 

Chemical  examination  of  the  gastric  contents  gives  a  result  similar 
to  that  found  in  gastric  carcinoma  (p.  385). 

In  the  spindle-celled  variety  gastric  symptoms  may  be  absent, 
but  haematemesis  was  observed  in  half  the  cases.  A  tumour  is  nearly 
always  present,  smooth,  painless,  and  mobile. 

Prognosis. — The  average  duration  of  life  is  about  fifteen  months 
in  round-celled  sarcoma,  twenty-eight  months  in  spindle-celled.  Death 
usually  occurs  from  exhaustion.  Perforation  has  taken  place  in  10  per 
cent,  of  the  cases  of  round-celled  sarcoma. 

Treatment. — This  is  the  same  as  for  carcinoma.  Ziesche  and 
Davidsohn  have  collected  records  of  53  operations,  in  32  of  which 
resection  was  carried  out,  with  a  mortality  of  25  per  cent. 

Partial  gastrectomy  on  the  lines  of  that  carried  out  for  carcinoma 
is  necessary  in  all  cases  of  diffuse  growth.  In  the  pedunculated  form, 
removal  of  the  growth  with  the  portion  of  gastric  wall  from  which 
it  springs  is  all  that  is  necessary. 

Gastrojejunostomy  should  be  carried  out  when  resection  is  im- 
possible and  pyloric  obstruction  is  present. 

SARCOMA   OF   THE   DUODENUM 

Primary  sarcoma  of  the  duodenum  is  extremely  rare.  As  a  rule 
it  is  round-celled  and  involves  the  whole  duodenum.  Obstruction  is 
rarely  produced,  the  lumen  of  the  gut  being  usually  increased. 

TUBERCULOSIS,  SYPHILIS,   FISTULA,  ETC 
TUBERCULOSIS    OF   THE    STOMACH 

Tuberculosis  of  the  stomach  is  usually  secondary  to  tuberculosis 
elsewhere,  most  often  in  the  lung.  It  may  occur  as  a  primary  lesion  ; 
Barchasch  states  that  6  cases  had  been  recorded  up  to  1907.  Of 
107  cases  studied  by  Ricard  and  Chevrier,  in  3  only  was  the  stomach 
alone  involved.  It  is  more  uncommon  than  tuberculous  infection  of 
the  intestine  ;  thus,  in  over  3,000  autopsies  on  tuberculous  subjects 
(Diirk,  Simmonds,  Letulle)  the  stomach  was  affected  13  times  only, 
whereas  intestinal  infection  is  stated  to  occur  in  over  50  per  cent, 
of  post-mortems  on  tuberculous  subjects. 

Infection  probably  occurs  through  an  erosion  becoming  infected 
by  the  tubercle  bacillus. 

Tuberculosis  of  the  stomach  presents  two  clinical  types — (1)  hyper- 
trophic ;    (2)  ulcerative 

1.  The  hypertrophic  variety  usually  affects  the  pyloric  region,  and, 
as  in  other  parts  of  the  alimentary  canal,  is  frequently  mistaken  for 
carcinoma.  This  is  the  least  usual  form  of  disease,  and  shows  itself 
by  symptoms  of  stenosis. 


SYPHILIS   OF   THE   STOMACH  397 

•_'.  A  tuberculous  ulcer  usually  occurs  is  the  body  of  the  Btomach, 
frequently  runs  transversely  to  the  axis  of  the  viscus,  and  bas  all 
the  characters  of  a  tuberculous  ulcer  elsewhere. 

The  symptoms  are  variable.  Perforation  and  bsematem 
rarely  occur.  In  one  patient,  a  man  of  34  who  was  under  my  care 
with  a  tuberculous  ulcer  of  the  anterior  wall  of  the  stomach,  the 
symptoms  were  indefinite  and  consisted  of  epigastric  pain  and  vomit- 
ing without  definite  relation  to  food.  In  addition  to  the  tuberculous 
ulcer  of  Btomach,  tuberculous  peritonitis  was  present.  Exploration 
was  followed  by  recovery,  and  the  patient  is  in  perfect  health  at  the 
time  of  writing,  four  years  after  operation. 

Prognosis  depends  upon  the  presence  and  condition  of  tubercle 
elsewhere  in  the  body. 

Treatment. — Operation  should  only  be  carried  out  to  relieve 
pyloric  obstruction,  when  -lastro-jejunostomy  should  be  performed. 
Otherwise  the  patient  should  be  subjected  to  general  treatment,  as 
adopted  for  tuberculosis  elsewhere. 

SYPHILIS    OF    THE    STOMACH 

Tertiary  syphilitic  lesions  may  be  found  in  the  stomach,  but  they 
are  rare,  not  more  than  50  cases  having  been  recorded.  The  disease 
starts  in  the  submucous  tissue,  and  may  be  diffuse  or  localized. 
Ulceration  follows  in  both  varieties ;  perforation  may  occur ;  a 
stricture  may  be  produced  at  either  orifice,  more  frequently  at  the 
pyloric ;  or  a  tumour  may  form,  simulating  carcinoma.  Of  12  cases 
observed  by  Bird,  11  were  situated  in  the  pyloric  region. 

The  disease  is  most  common  in  men  between  the  ages  of  25  and 
40.  Fenwick  states  that  pain  and  vomiting  are  more  severe  and 
haemorrhage  is  less  common  than  in  simple  ulcer. 

Diagnosis. — There  is  no  single  symptom  or  combination  of 
symptoms  which  will  enable  the  diagnosis  to  be  made  from  a  chronic 
gastric  ulcer  or  malignant  growth.  Its  presence  should  be  suspected 
when  gastric  symptoms  occur  in  a  syphilitic  patient,  and  will  be 
confirmed  if.  after  resistance  to  the  usual  measures  of  treatment,  they 
subside  under  mercury  and  iodides. 

Partial  gastrectomy  has  been  performed  (Tuffier,  Bird)  for  what 
was  considered  to  be  carcinoma  but  proved  to  be  a  gummatous  tumour. 
In  nearly  all  the  cases  other  abdominal  manifestations  of  syphilis  are 
present.  Stress  is  laid  upon  peritoneal  involvement  and  the  occur- 
rence of  gummata  in  the  liver.  With  regard  to  the  former,  Bird  has 
frequently  noted  the  presence  of  bluish  striae  following  the  course  of 
the  lymphatics,  or  of  opaque  bluish-white  patches  on  the  peritoneal 
coat. 

It   must  be  remembered  that  gastric   symptoms   frequently  arise 


398  THE   STOMACH   AND    DUODENUM 

in  patients  taking  antisyphilitic  remedies  by  the  mouth,  and  that 
gastric  syphilis  is  a  late  manifestation. 

Treatment — The  usual  antisyphilitic  remedies  should  be  given. 
If  pyloric  or  cardiac  stenosis  is  present,  unaffected  by  drugs,  gastro- 
jejunostomy or  gastrotomy  must  be  undertaken. 

PLASTIC   LINITIS   (CIRRHOSIS   OF   STOMACH;    FIBRO- 
MATOSIS  OF   STOMACH— Alexis  Thomson) 

This  rare  disease,  first  named  cirrhosis  of  stomach  by  Andral  in 
1845,  was  accurately  described  by  Brinton  in  1859.  It  is  characterized 
by  a  diffuse  fibrous  thickening  usually  starting  at  the  pyloric  region, 
chiefly  involving  the  submucous  coat,  and  diminishing  the  capacity 
of  the  stomach.  Writers  are  by  no  means  agreed  that  this  condition 
is  a  clinical  entity,  but  there  seems  to  be  no  doubt  that,  although 
rare,  such  a  condition  exists.  Definite  cases  have  been  recorded  by 
Osier,  Leith,  Sheldon,  and  Jonnesco.  It  may  be  impossible,  even 
after  microscopical  examination  of  the  stomach  or,  in  most  cases,  of 
the  enlarged  lymphatic  glands,  to  say  if  the  condition  is  simple  (plastic 
linitis)  or  malignant  (diffuse  scirrhus  carcinoma),  for  the  section  exam- 
ined may  show  no  sign  of  malignancy,  but  secondary  deposits  of  car- 
cinoma may  be  present  in  the  liver ;  or  the  after-course  only  may 
render  the  diagnosis  certain.  I  have  had  4  cases  under  my  care ; 
in  3  the  section  of  the  stomach  wall  showed  no  sign  of  malignancy, 
but  in  one  of  these  secondary  growths  were  present  in  the  liver,  and 
in  another  the  after-progress  left  no  doubt  that  the  growth  was 
malignant.  ■> 

The  causation  of  the  condition  is  obscure  when  those  cases 
secondary  to  diffuse  atrophic  carcinoma  are  excluded. 

It  is  a  disease  of  adult  life  more  common  in  men  than  in  women. 
The  stomach  is  of  normal  size  or  contracted  ;  it  may  be  freely  mobile 
or  fixed  by  adhesions  ;  externally  it  presents  a  peculiar  pearly- white 
appearance.  On  section  it  is  found  to  be  of  diminished  capacity, 
and  all  its  coats  stand  out  (see  Fig.  386).  The  thickening  chiefly 
affects  the  submucous  coat,  which  is  many  times  the  normal  thickness. 
The  mucous  membrane  is  not  usually  affected.  The  change  is,  as  a 
rule,  most  marked  in  the  pyloric  region. 

Symptoms. — As  pointed  out  by  Brinton,  the  condition  may  be 
found  after  death,  no  symptoms  having  been  produced  during  life. 

It  is  a  disease  of  insidious  onset,  with  pain  and  vomiting.  The 
patient  loses  weight,  and  a  tumour  is  usually  found  extending  from 
under  the  left  costal  margin.  Rarely,  free  fluid  may  be  present  in  the 
peritoneal  cavity.  Free  HC1  is  usually  absent  from  the  gastric  con- 
tents after  a  test  meal. 

Diagnosis. — This  should  be  suggested  by  a  tumour  under  the 


PHLEGMONOUS   GASTRITIS 

left  costal  maigin,  if   there  Is  difficulty  in  inflating  the  stomach  and 

the  stomach  will  not  hold  more  than  a  small  quantity  of  fluid. 

Treatment.— -When  possible,  gastrectomy,  complete  or  partial, 
should  be  done,  for  it  is  impossible  to  be  certain  whether  the  condition 
is  simple  or  malignant.  Mbynihan  has  recorded  a  case  which  appeared 
clinically  to  be  one  of  plastic  linitis,  for  which  he  successfully  per- 
formed total  gastrectomy ;  microscopic  examination  later  showed 
the  growth  to  be  malignant.  Where  this  treatment  is  not  feasible, 
gastrojejunostomy  should  be  performed  if  the  condition  of  the  stomach 
will  permit.  Sheldon  has  recorded  a  case  well  three  and  a  half  years, 
Deaver  one  well  two  and  a  half  years  after  this  operation.  It  may 
be  necessary  to  perform  jejunostomy. 

PHLEGMONOUS   GASTRITIS    (SUBMUCOUS   GASTRITIS; 
SUPPURATIVE   LINITIS) 

This  is  a  rare  condition  of  diffuse  inflammation  of  the  submucous 
layer  of  the  stomach,  occasionally  going  on  to  suppuration. 

Since  the  recognition  of  the  disease  by  P.  Borel,  in  1656,  the  number  of 
recorded  cases  is  under  100.  The  condition  is  more  common  in  men  than  in 
women,  and  may  occur  at  any  age,  but  is  most  often  seen  between  20 
and  40.     In  25  per  cent,  of  the  cases  there  is  a  history  of  chronic  alcoholism. 

Etiology  and  pathology — Phlegmonous  gastritis  is  an  infec- 
tive cellulitic  inflammation  of  the  submucous  tissue  of  the  stomach, 
which  may  diffusely  involve  the  whole  stomach  or  be  localized.  The 
infecting  micro-organism  present  is  usually  a  streptococcus.  In  a 
case  recorded  by  J.  E.  Adams  a  pure  culture  of  pneumococcus  was 
obtained.  The  organism  may  obtain  entrance  through  an  ulcer,  simple 
or  malignant,  or  a  wound,  accidental  or  operative.  In  some  cases  the 
origin  of  the  infection  cannot  be  discovered ;  in  others  it  is  associated 
with  some  acute  infective  disease,  such  as  typhoid  or  puerperal  fever  ; 
whilst  cases  have  been  recorded  following  the  ingestion  of  infected 
food.  There  are,  therefore,  two  groups — primary,  in  which  the  infec- 
tion occurs  through  a  lesion  of  the  stomach  wall ;  and  secondary, 
complicating  other  diseases.  J.  E.  Adams  has  recently  suggested  that 
the  term  primary  should  be  applied  only  to  those  cases  in  which  no 
naked-eye  lesion  of  the  gastric  wall  can  be  discovered ;  secondary,  to 
those  in  which  the  infection  spreads  from  an  ulcer,  simple  or  malig- 
nant, or  from  an  operation  wound.  But  as  it  is  probable  that  in  all, 
except  those  complicating  disease  elsewhere,  the  micro-organism  gains 
entrance  through  the  wall  of  the  stomach,  the  term  primary  should 
not  be  limited  to  those  in  w7hich  the  seat  of  entrance  is  visible  to  the 
naked  eye 

The  stomach-wall  is  increased  in  thickness,  often  to  eight  or  nine 
times  its   normal   size.     The   peritoneal   coat  in   the    early   stage  is 


4°o  THE   STOMACH   AND    DUODENUM 

unaltered,  but  in  the  later  stage  shows  signs  of  inflammation.  The 
mucous  membrane  is  swollen  and  often  hypcrsemic  and  ecchymotic. 
The  submucous  coat  is  markedly  thickened,  yellowish-white  in  appear- 
ance, and  soft,  and  occasionally  presents  tiny  abscesses.  Peritonitis  is 
found  in  most  of  the  cases.  When  the  disease  is  circumscribed  the 
pyloric  end  is  most  often  affected,  and  a  localized  abscess  may  form. 

A  similar  condition  may  occur  in  the  duodenum.  Ungermann  has 
recently  collected  6  cases  of  phlegmonous  duodenitis,  in  3  of  which 
the  disease  was  localized  in  the  duodenum  alone.  The  inflammation 
was  most  marked  in  the  region  of  the  biliary  papilla. 

Symptoms — The  onset  is  usually  sudden,  with  severe  epigastric 
pain,  vomiting,  and  prostration.  The  pain  is  constant  and  accompanied 
at  first  by  localized  rigidity.  The  patient  is  obviously  suffering  from 
some  acute  septic  condition ;  the  pulse  is  feeble,  the  temperature  is 
elevated,  and  the  tongue  is  dry  and  furred.  Later  the  signs  of  general 
peritonitis  are  added. 

Prognosis. — No  case  of  generalized  phlegmonous  gastritis  lias 
recovered.  In  a  case  of  the  localized  variety,  in  which  a  definite 
abscess  formed,  recovery  followed  operation  and  evacuation  of  the 
abscess  (Bovee)  ;  and  in  a  similar  case  spontaneous  recovery  followed 
rupture  of  the  abscess  into  the  stomach,  the  pus  being  vomited. 

Diagnosis. — This  has  so  far  never  been  made  before  operation  ; 
and  when  we  consider  that  it  has  to  be  made  from  a  perforative  lesion 
of  the  stomach  or  duodenum  and  acute  pancreatitis,  it  is  unlikely 
that  it  will  often  be  possible.  The  ldstory  of  alcoholism,  the  frequent 
vomiting,  and  the  profound  general  disturbance  should  cause  the 
condition  to  be  suspected. 

In  the  localized  form,  after  an  acute  onset  the  symptoms  abate, 
and  a  swelling  palpable  through  the  abdominal  wall  may  form.  This 
may  rupture  into  the  peritoneal  cavity,  causing  general  peritonitis, 
or  into  the  stomach  ;    recovery  has  followed  the  latter  accident. 

Treatment. — In  the  diffuse  variety,  if  exploration  is  undertaken 
before  general  peritonitis  has  supervened,  multiple  incisions  down  to 
the  submucosa  should  be  made  after  packing  over  the  stomach  area 
with  gauze.  In  the  localized  form,  incision  and  drainage  should  be 
carried  out. 

GASTRIC   AND    DUODENAL   FISTULA 

Fistubc  connected  with  either  stomach  or  duodenum  are  rare. 
The  fistula  may  be  an  "internal"  one  connecting  the  organ  with 
another  viscus,  or  an  "  external  "  one  opening  on  the  surface  of  the 
body.  Of  gastric  fistula?,  the  internal  is  the  more  common ;  a 
duodenal  fistula  is  much  rarer,  and  here  the  external  fistula  is  more 
frequent  than  the  internal. 


EXTERNAL    FISTULjE   OF   STOMACH  i   ' 

(iASTKh     l''i-  i  i  I.  1: 

On  account  of  the  development  of  gastric  Burgery  these  cases  are 
rarer  now  than  formerly;  externa]  gastric  fistula?  are  particularly 
uncommon. 

External  Fistula 
Fall  into  two  groups,  the  traumatic  and  the  pathological,  the  latter 
being  divided  into  primary,  in  which  the  causal  disease  originates 
in  the  stomach,  and  secondary,  in  which  it  begins  in  a  neighbour- 
ing organ.  Lieblein  and  Hilgenreiner  based  their  article  (Deutsche 
Chirurgic)  in  1905  on  120  published  cases.  Formerly  gastric  ulcer  was 
the  most  common  cause  ;  now  it  is  rarely  seen  except  in  advanced 
malignant  disease. 

1.  Traumatic. — Alexis  St.  Martin  was  the  most  celebrated  example 
of  this  condition.  Fistula?  rarely  form  nowadays  as  the  result  of 
injuries  to  the  stomach,  immediate  operation  saving  the  patient 
from  this  risk.  Cases  have  been  recorded  in  which  a  foreign  body 
swallowed  has  perforated  the  stomach,  caused  a  perigastric  abscess 
which  has  opened  externally,  and  thus  led  to  a  gastric  fistula.  A 
fistula  occasionally  follows  operations  upon  the  stomach  and  neigh- 
bouring organs  ;  and  cases  have  been  recorded  following  operations 
upon  pancreatic  cysts,  cholecysto-gastrostomy,  gastroenterostomy,  and 
nephrectomy. 

2.  Pathological,  (a)  Primary. — In  both  simple  and  malignant 
ulcers  of  the  stomach,  fistula  may  be  a  secondary  result  of  subacute 
perforation,  a  perigastric  abscess  forming,  which  is  opened  or  bursts 
through  the  anterior  abdominal  wall.  In  a  few  cases  the  fistula  may 
lie  the  result  of  the  direct  involvement  of  the  abdominal  wall. 

Cases  have  been  recorded  in  which  the  stomach  was  contained  in 
a  strangulated  ventral  hernia,  and  a  fistula  followed  operation. 

(b)  Secondary. — These  are  usually  due  to  disease  of  the  liver  and 
gall-bladder ;  cases  have  also  been  recorded  after  operation  upon 
hydatid  cysts  of  liver,  etc. 

Symptoms. — The  characteristic  feature  is  the  discharge  of 
stomach  contents  from  an  opening,  situated  in  most  cases  in  the 
lower  epigastric  region,  the  umbilical  region,  or  the  left  hypochondrium. 
If  it  is  small,  very  little  effect  is  produced  on  the  general  condition 
of  the  patient ;  if  the  discharge  is  great  the  patient  wastes,  and  much 
discomfort  is  caused  by  irritation  of  the  skin. 

The  diagnosis  may  have  to  be  made  from  duodenal  fistula  ;  this 
is  usually  easy  from  the  position  of  the  external  opening,  and  is 
facilitated  by  noting  the  characters  of  the  discharge  and  the  lapse 
of  time  between  ingestion  of  food  and  its  appearance  at  the  opening. 
In    a   gastric  fistula,  food    generally  appears  within   a   short  time  of 

9  „ 


402  THE   STOMACH   AND   DUODENUM 

ingestion,  while  delay  occurs  in  duodenal  fistula  and  the  discharge  is 
often  bile-stained. 

Prognosis. — This  depends  upon  the  causation.  Patients  have 
lived  as  long  as  thirty-five  years  after  the  formation  of  the  fistula. 
If  the  pylorus  is  unobstructed  and  the  fistula  not  large,  spontaneous 
healing  will  occur  ;  thus,  it  takes  place  in  most  postoperative  cases 
and  in  those  following  the  perforation  of  ulcers  on  the  anterior  surface 
of  the  stomach. 

Treatment. — Resort  to  operative  treatment  should  not  be 
hurried  unless  the  escape  of  gastric  contents  is  great.  In  these  cases, 
after  packing  the  external  opening  with  gauze  and  thoroughly  cleaning 
the  skin  in  its  neighbourhood,  an  elliptical  incision  should  be  made 
around  it,  the  peritoneal  cavity  opened,  the  fistulous  tract  dissected 
down  to  the  stomach,  and  the  opening  closed.  If  the  fistulse  is  due  to 
malignant  disease,  or  the  condition  of  the  patient  will  not  permit  of 
extensive  operation,  jejunostomy  may  be  performed.  Where  the 
condition  is  not  interfering  with  the  general  health,  it  may  be  left  in 
the  hope  that  it  will  eventually  close. 

Internal  Fistulce 

These  may  be  the  result  of  injuries  (usually  operative),  or  of  disease, 
primary  or  secondary.  The  communication  is  most  frequently  with 
the  colon,  more  rarely  with  the  gall-bladder,  duodenum  (Plate  91), 
lung,  pancreas,  urinary  tract,  or  oesophagus. 

Gastro-colic  fistula  is  usually  the  result  of  carcinoma  (65 
out  of  84  cases — Chavannaz),  mostly  of  the  stomach,  much  less  fre- 
quently of  the  colon.  It  may  result  from  simple  ulcer,  tuberculous 
disease  of  colon,  perigastric  abscess  due  to  disease  of  neighbouring 
organs,  or  ulcer  of  the  jejunum  following  gastro- jejunostomy. 

The  fistulous  opening  in  the  stomach  is  most  common  at  the  greater 
curvature  near  the  pyloric  end  ;  that  in  the  colon,  in  the  middle  of 
the  transverse  part. 

Symptoms. — The  condition  may  exist  without  giving  rise  to 
symptoms,  but  in  the  majority  of  cases  they  are  definite  and  consist 
of  fsecal  vomiting  and  diarrhoea,  the  motions  containing  undigested 
food  which  in  some  cases  appears  soon  after  it  has  been  taken.  In 
many  cases  a  similarity  between  motion  and  vomit  has  been  noticed. 

Diagnosis  may  be  confirmed,  if  this  is  necessary,  by  distending 
the  stomach  or  colon  with  air.  No  difficulty  arises  except  in  hysterical 
women. 

Sir  Frederick  Treves  recorded  an  example — a  woman  of  20  vomited 
formed  faeces,  and  an  enema  of  methylene  blue  a  few  minutes  after  it  was 
given  ;  at  operation,  all  abdominal  organs  were  normal.  The  patient  had 
undergone  two  operations  previously.  Similar  cases  have  been  reported  by 
others. 


Pylorui 


Duode 


Gastro-duodenal  fistula,  the   result  of   carcinoma  of  the  stomach. 
The  probe  passes  from  stomach  to  duodenum. 

{Pathological  Institute,   London  Hospital.) 


PLATE   91. 


DUODENAL    HSTII.  i: 

No  mistakes  should  occur  If  the  existence  of  these  casee  ie  remem- 
bered,  for  they  occur  in  well-nourished,  hysterical  women,  whei 

the   patients   with   uastro-colic  fistula  arc  obviously  ill. 

Prognosis. — This  is  bad.  Spontaneous  closure  is  said  to  have 
occurred  in  two  cases. 

Treatment  will  depend  upon  the  causation.  If  this  is  malignanl 
growth,  wide  dissection  followed  by  end-to-end  suture  of  colon  and 
partial  gastrectomy  (p.  404)  should  be  performed  if  possible.  If  the 
growth  is  too  far  advanced  to  admit  of  this,  short-circuiting  operations 
should  be  done. 

Other  kinds  of  Internal  Fistula} 

Fistulous  communications  between  the  gall-bladder  and  biliary 
passages  and  stomach  or  duodenum,  although  relatively  rare,  are, 
after  the  gastro-colic,  the  most  common  form  of  fistula.  Cases  have 
been  recorded  in  which  patients  vomited  gall-stones  ;  more  often  the 
fistulous  communication  is  with  the  duodenum,  and  no  symptoms 
result  unless  a  stone  passes  into  the  intestines  large  enough  to  cause 
intestinal  obstruction. 

The  symptoms  of  a  stomach-gall-bladder  fistula  are  usually  bilious 
vomiting  and,  in  some  cases,  dilatation  of  the  stomach  due  to  sur- 
rounding adhesions. 

Treatment. — The  gall-bladder  should  be  separated  from  the 
stomach,  and  the  opening  into  the  latter  closed.  The  gall-bladder 
should  be  drained  or  removed,  according  to  its  condition,  and  gastro- 
jejunostomy done  if  necessary. 

Duodenal  Fistula 

These  are  rare.  They  may  follow  operation  upon  gall-bladder, 
duodenum,  or  kidney,  particularly  the  first-named,  the  duodenum 
being  torn,  or  injured  by  the  pressure  of  a  drainage-tube.  When  the 
duodenum  has  been  mobilized  for  the  purpose  of  removing  a  stone 
from  the  retroduodenal  portion  of  the  common  duct,  a  fistula  may 
result.  Fistula  is  not  an  uncommon  sequel  to  the  perforation  of  a 
duodenal  ulcer ;  it  may  follow  suture,  the  opening  of  a  subdiaphrag- 
matic abscess  or  of  one  due  to  retroperitoneal  perforation  ;  the  external 
opening  is  usually  in  the  right  hypochondrium,  but  in  the  case  last 
mentioned  may  be  in  the  loin  or  even  in  the  inguinal  region. 

Internal  fistulas  have  been  described,  the  duodenum  communicating 
with  stomach  or  colon.  These  are  pathological  curiosities.  The  only 
common  form  is  that  between  duodenum  and  gall-bladder  secondary 
to  disease  of  the  latter. 

Prognosis. — In  the  cases  following  operation  the  fistula  usually 
heals  spontaneously.  Recovery  is  recorded  in  one  case  only  (Lawford 
Knaggs)  following  perforation  of  an  ulcer. 


4o4  THE   STOMACH    AND   DUODENUM 

Treatment. — The  treatment  is  on  the  same  lines  as  in  external 
gastric  fistula)  (p.  402).  If  spontaneous  closure  does  not  occur  or 
delay  is  inadvisable,  gastrojejunostomy  should  be  performed  with 
simultaneous  closure  of  the  pylorus  by  infolding.  This  was  carried 
out  in  Lawford  Knaggs'  case. 

GASTRIC  OPERATIONS 

General  considerations. — Care  must  be  taken  to  render  the 
upper  part  of  the  alimentary  tract  as  sterile  as  possible  ;  the  mouth 
must  be  attended  to,  and  all  septic  teeth  treated.  For  twenty-four 
hours  before  operation,  nothing  but  sterile  milk  or  Benger's  food 
should  be  given.  If  examination  gives  evidence  of  gastric  stasis,  the 
stomach  should  be  washed  out  an  hour  before  operation  ;  if  dilata- 
tion is  great,  lavage  should  be  employed  twice  a  day  for  several  days 
before  operation  is  undertaken. 

When  the  abdomen  has  been  opened,  the  whole  of  the  stomach  and 
duodenum  must  be  carefully  examined  ;  then  the  condition  of  other 
organs — particularly  the  gall-bladder  and  appendix — investigated. 

After  recovering  from  the  effects  of  the  anaesthetic  the  patient 
should  be  propped  up  in  bed,  and  nursed  as  far  as  possible  in  this 
position.  When  lying  down  the  dorsal  position  is  unnecessary,  and 
the  patient  may  be  turned  from  side  to  side  as  desired.  Vomiting 
is  unusual,  and  during  the  first  twenty-four  hours  the  patient  should 
be  allowed  to  drink  as  much  water  as  he  wishes.  On  the  day  following 
operation,  milk,  Benger's  food,  bread  and  milk,  and  tea  can  be  given, 
and  solid  food  usually  by  the  second  week.  For  the  first  week  or 
ten  days  the  patient  is  better  in  bed,  but  he  may  be  allowed  up  about 
the  tenth  day.  This  rule  may  be  broken  without  fear  of  evil  conse- 
quences, if  confinement  to  bed  is  inadvisable,  unless  the  wound  has 
been  allowed  to  remain  open  for  drainage.  An  action  of  the  bowels 
should  be  obtained  by  enema  the  day  following  operation. 

GASTRECTOMY 

Gastrectomy  may  be  described  under  two  headings,  partial  and 
complete.  The  term  partial  gastrectomy  should  be  restricted  to  a 
definite  operation,  i.e.  removal  of  the  pyloric  portion  of  the  stomach 
together  with  the  whole  of  the  lesser  curvature  and  a  varying  portion 
of  the  greater  curvature,  never  less  than  its  pyloric  half.  When  small 
portions  of  the  stomach-wall  are  removed  the  operation  should  be 
called  resection.  In  complete  gastrectomy  the  whole  of  the  stomach 
is  removed,  from  the  duodenum  to  the  oesophagus. 

Partial  Gastrectomy 
In  this  operation,  when  carried  out  (as  it  usually  is)  for  malignant 
disease,  in  addition  to  the  part  of  the  stomach  mentioned  above,  the 


PARTIAL   GASTRECTOMY 

primary  lymphatic  glands,  the  Lesser  omentum,  and  as  much  as  pos- 
sible of  the  great  omentum  must   be  removed,  together  with  aboul 

hi  inch  of  the  duodenum. 

Closure  of  the  gastric   and   duodenal   out  <'ii<ls  and   anaston 
by  gastroenterostomy  (Billroth  II.)  is  certainly  preferable  either  to 

Billroth's  original  operation  of  pylorectomy  combined  with  end-to- 
end  junction  (Billroth  L,  1881),  or  to  Kocher'fl  modification  in  which 
he  closed  the  cut  end  of  the  stomach  and  implanted  the  open  duodenal 
end  into  the  posterior  gastric  wall.  If  sufficient  stomach  is  removed 
both  of  these  methods  are  difficult  and  are  liable  to  permit  leakage. 

After  ligaturing  and  dividing  the  lesser  omentum  close  to  the 
liver,  and  the  pyloric  and  gastro-duodenal  arteries  close  to  their 
origin  from  the  hepatic,  the  operator  divides  the  left  gastro- 
epiploic artery  between  ligatures,  and  then  inserts  his  hand  into  the 
lesser  sac  behind  the  stomach  so  as  to  free  it,  if  necessary,  from  the 
pancreas,  and  to  separate  the  anterior  layers  of  the  great  omentum 
from  the  transverse  mesocolon.  Care  is  necessary  at  this  stage  to  avoid 
the  middle  colic  artery.  Injury  to  this  vessel  has  resulted  in  the  death 
of  the  patient  from  gangrene  and  perforation  of  the  transverse  colon. 

The  duodenum  is  then  divided  between  clamps  at  least  an  inch 
beyond  the  pylorus,  and  closed  wTith  through-and-through  stitches 
of  fine  chromic  gut,  buried  by  a  continuous  silk  stitch.  All  the  fatty 
tissue  and  glands  in  the  angle  between  the  stomach  and  duodenum 
must  be  removed. 

The  coronary  artery  is  then  sought  at  its  origin  and  divided,  and 
all  the  tissue  here  removed  down  to  the  stomach.  The  stomach  can 
then  be  pulled  well  over  to  the  left.  Posterior  gastro-jejunostomy 
should  be  performed,  the  stomach  removed  between  two  clamps, 
and  the  cut  end  closed  in  a  manner  similar  to  that  adopted  for  the 
duodenum.  The  right  suprapancreatic  glands  lying  along  the  hepatic 
artery  should  be  then  sought  for  and  removed. 

It  may  be  necessary  to  excise  the  whole  or  a  portion  of  the  trans- 
verse colon  with  the  stomach,  either  because  it  is  invaded  by  the  growth 
or  because  its  blood-supply  is  endangered. 

Hey  Groves  has  suggested  that  operation  in  twTo  stages  would 
lower  the  death-rate.  A  two-stage  operation  should  only  be  per- 
formed in  pyloric  carcinoma  when  the  condition  of  the  patient  is  bad, 
or  when  the  diagnosis  is  uncertain.  A  preliminary  gastro-jejunostomy 
is  useless  if  the  growth  is  not  producing  obstruction.  In  two  cases 
of  my  own,  after  gastro-jejunostomy  for  early  malignant  growth  of 
the  pylorus,  in  which  the  condition  of  the  patient  did  not  justify  a 
one-stage  operation,  the  second  stage  was  refused  on  account  of  the 
great  improvement  which  had  taken  place,  and  both  patients  died 
within  eighteen  months. 


406  THE   STOMACH   AND   DUODENUM 

Rodman's  operation. — This  is  a  variety  of  partial  gastrectomy 
performed  for  indurated  ulcer  of  the  pyloric  end  of  the  stomach  in 
cases  in  which  the  diagnosis  from  carcinoma  is  uncertain.  Rodman 
excises  the  ulcer-bearing  area  in  all  cases  of  pyloric  ulcer.  His  opera- 
tion differs  from  that  just  described  in  that  the  whole  of  the  lesser 
curvature,  the  duodenum,  or  glands  need  not  be  removed,  but  both 
duodenum  and  stomach  should  be  closed  and  posterior  gastrojejun- 
ostomy performed. 

Complete  Gastrectomy 

The  operation  is  begun  as  in  partial  gastrectomy,  but  the  entire 
great  omentum  and  then  the  gastro-splenic  omentum  are  ligatured  off. 
After  division  of  the  coronary  artery  the  stomach  can  be  pulled  well 
out.  It  should  not  be  removed  yet,  but  a  coil  of  jejunum  brought 
up,  clamped,  and  united  to  the  extreme  cardiac  end  of  the  stomach 
by  stitches  passing  through  serous  and  muscular  coats.  An  opening 
is  then  made  in  both,  and  gradually  enlarged  as  stitches  are  put  in 
through  all  the  coats  of  each  viscus,  the  stomach  in  this  way  being 
removed.  Finally,  the  operation  is  completed  by  the  insertion  of  an 
anterior  row  of  sero-muscular  stitches  ;  or  the  jejunum  may  be  divided 
completely,  its  distal  end  anastomosed  to  the  oesophagus,  and  its 
proximal  into  its  distal  portion. 

GASTROENTEROSTOMY 

fc*   This  operation  consists  in  making  an  anastomosis  between  the 

stomach  and  the   small   intestine.     The   jejunum  is  usually   chosen 

(gastrojejunostomy),  in  a  few   cases  the  duodenum  (gastro-duoden- 

ostomy). 

Gastrojejunostomy 

This  may  be  performed  to  the  anterior  or  posterior  surface  of  the 
stomach.  The  latter  is  the  operation  of  choice.  At  first  a  loop 
was  left  between  the  anastomosis  and  the  duodeno-jejunal  junction, 
but  this  should  never  be  done  (see  p.  413). 

Posterior  Gastrojejunostomy 
After  careful  examination  of  the  stomach,  the  transverse  colon 
and  omentum  are  withdrawn  from  the  abdomen  and  an  opening  made 
in  the  transverse  mesocolon,  beginning  close  to  the  point  at  which 
it  is  in  contact  with  the  jejunum.  The  opening  should  then  be 
enlarged,  care  being  taken  to  avoid  injury  to  vessels.  The  portion 
of  stomach  wall  which  is  to  be  used  for  the  anastomosis  is  drawn 
through  this  opening  and  clamped  in  a  vertical  direction  from  the 
lesser  to  the  greater  curvature.  The  duodeno-jejunal  flexure  is  now 
carefully  examined  (the  jejunum  at  its  origin  should  always  be  seen) 
(p.  299).     The  jejunum  is  then  stretched  tightly  from  the  duodeno- 


Fig.  390. — Gastrojejunostomy  by  the  four-stitch  method. 
(See  text,  p.  408.) 


408  THE   STOMACH  AND   DUODENUM 

jejunal  flexure  and  a  second  clamp  applied,  care  being  taken  that  the 
jejunum  does  not  become  twisted  longitudinally.  At  least  3  in. 
of  stomach  and  jejunum  should  be  in  the  clamps.  A  strip  of  gauze 
should  be  placed  between  the  clamps,  the  stomach  and  jejunum 
brought  together,  and  the  omentum,  colon,  and  rest  of  the  stomach 
returned  to  the  abdomen.  In  performing  the  anastomosis  four 
stitches  are  used,  two  of  silk  and  two  of  chromic  gut.  The  stomach 
and  jejunum  are  first  united  by  two  silk  .stitches  passing  through 
serous  and  muscular  coats  at  least  3  in.  apart  (Fig.  390).  The  thread 
at  the  patient's  right  is  then  taken,  and  a  continuous  sero-muscular 
stitch  inserted  from  right  to  left.  On  reaching  the  left  stitch  it  is 
tied  off,  and  its  end  tied  to  the  loose  end  of  the  left  stitch.  The  viscera 
are  opened,  redundant^  mucous  membrane  is  removed,  and  a  chromic- 
gut  stitch  passed  at  each  end  of  the  opening  through  all  the  coats  of 
the  stomach  and  jejunum.  The  right-hand  needle  is  then  taken  and 
a  continuous  stitch  inserted,  care  being  exercised  to  pass  the  needle 
through  all  the  coats  and  to  insert  them  sufficiently  closely  to  stop  all 
bleeding.  This  stitch  is  tied  off  in  a  way  similar  to  that  adopted  for  the 
silk.  The  left  stitch  of  chromic  gut  is  inserted  continuously  from  left  to 
right  and  tied  off.  After  removal  of  the  clamps  the  left  silk  stitch 
is  taken,  and  the  sero-muscular  suture  finished  anteriorly. 

The  posterior  surface  of  the  anastomosis  is  inspected  by  pulling 
on  the  gauze,  and  finally  the  opening  in  the  mesocolon  is  stitched  to 
the  stomach  close  to  the  line  of  anastomosis.  Performed  in  this  way 
the  results  are  most  satisfactory. 

Various  modifications  have  been  suggested  and  used.  Mayo  unites 
the  jejunum  to  the  stomach  in  such  a  manner  that  it  passes  to  the 
left.  This  has  not  proved  so  satisfactory  in  the  hands  of  other 
surgeons  as  the  vertical  operation  described  above. 

Anterior  Gastro-Jejunostomy 
This  was  the  original  operation  performed  by  Wolfer  in  1881. 
It  should  only  be  carried  out  when  conditions  render  the  posterior 
operation  impossible.  As  usually  performed  it  is  a  "  loop  "  operation. 
A  portion  of  the  jejunum  18  to  24  in.  from  the  duodenojejunal  flexure 
is  taken  and  brought  up  beneath  and  then  in  front  of  the  transverse 
colon,  and  united  to  the  anterior  surface  of  the  stomach.  This  loop 
is  unnecessary  and  dangerous.  Since  1904  I  have  always  performed 
the  anterior  operation  without  a  loop.  This  operation  is,  I  believe, 
original,  the  nearest  approach  to  it  being  the  operation  described  by 
Brenner  in  1891,  in  which  the  jejunum  was  brought  to  the  stomach 
by  the  same  route  but  a  long  loop  was  left.  The  duodenojejunal 
junction  is  found  and  an  opening  made  in  the  transverse  mesocolon 
and  gastro-colic  omentum  immediately  over  it ;  a  portion  of  jejunum 


QDnoO? 


<->    i 


410 


THE   STOMACH   AND   DUODENUM 


close  to  the  duodenojejunal  flexure  is  brought  up  through  this  and 
united  to  the  anterior  surface  of  the  stomach  (Fig.  390).  At  the 
end  of  the  operation  the  opening  in  the  great  omentum  is  stitched 
around  the  stomach. 

I  have  performed  this  operation  now  on  26  occasions,  and  have 


POSTERIOR  0  £. 


GREAT 
OMENTUM 


/INTER/OR  LOOP 
OR  PRE-COUC  6.E. 


INTERIOR    "NO  LOOP" 
OR  RETRO -COLIC   GE 

Fig.  392. — To  illustrate  the  three  methods  of  gastrojejunostomy. 

never  had  trouble,  convalescence  being  as  smooth  as  after  the 
posterior  no-loop  operation,  with  complete  absence  of  any  biliary 
regurgitation.  The  first  patient  upon  whom  I  performed  the  opera- 
tion, for  a  saddle-shaped  chronic  gastric  ulcer,  died  of  another 
cause  twenty-eight  months  later ;  the  ulcer  was  healed,  and  the 
anastomosis  was  described  by  the  pathologist  as  posterior. 

Gastro-Enterostomy  in  Y  :     Roux's  Operation 
In  this  modification  of  posterior  gastrojejunostomy  the  jejunum 
is  completely  divided  10  or  12  in.  below  the  duodenojejunal  flexure, 


RESULTS   OF   GASTROJEJUNOSTOMY 


•i' ' 


its  distal  end  implanted  into  the  posterior  surface  of  the  Btomach, 
and  its  proximal  into  the  jejunum  aboul  1  in.  below  its  junction  with 
the  stomach. 

The  operation  should  nol  be  performed  it'  it.  is  possible  to  do  either 
of  those  just  described.  It  is  liable  to  be  followed  by  ulcer  of  the 
jejunum  (see  p.    1 1 1). 

Results  of  gastrojejunostomy.  It  is  beyond  dispute  thai 
the  performance  of  gastrojejunostomy  is  followed  by  the   healing  of 


Fig.  393. — -Anterior  no-loop  gastrojejunostomy,  completed 
except  for  suturing  the  opening  in  the  great  omentum 
around   the  anastomosis. 

a  chronic  ulcer  of  the  stomach  or  duodenum  (see  p.  351).  Much  work 
has  been  done  on  the  X-ray  examination  of  the  stomach  after  experi- 
mental gastrojejunostomy  on  animals,  with  results  that  are  widely 
divergent  from  those  obtained  in  a  similar  examination  on  patients. 
Cannon  and  Blake,  Kelling,  and  Delbet  considered  that  nothing  passed 
out   by   the   anastomotic   opening.     In   one   of   Cannon   and    Blakes' 


4i2  THE   STOMACH   AND   DUODENUM 

experiments,  in  which  an  exceptionally  large  opening  was  found  in 
the  pyloric  portion  of  the  stomach,  some  of  the  food  passed  out  by 
this  channel.  On  the  other  hand,  Pers  of  Copenhagen  published  in 
1909  the  results  of  X-ray  examination  of  40  patients  upon  whom 
he  had  performed  gastrojejunostomy,  and  found  that  in  38,  irrespec- 
tively of  the  permeability  of  the  pylorus,  a  bismuth  meal  passed  only 
through  the  anastomosis,  that  in  one  case  it  passed  through  bdth 
anastomosis  and  pylorus,  and  that  in  one  its  course  could  not  be  ascer- 
tained. In  24  cases  the  food  began  to  leave  the  stomach  at  once. 
This  is  in  agreement  with  a  case  recorded  by  H.  M.  W.  Gray,  in  which, 
after  gastrojejunostomy,  pyloric  obstruction  not  being  present,  food 
preferred  to  leave  by  the  anastomotic  opening. 

Cases  have  been  recorded  in  which,  after  gastrojejunostomy 
carried  out  for  the  treatment  of  a  duodenal  fistula,  food  still  passed 
through  the  pylorus  and  escaped  at  the  fistula. 

In  comparing  these  results  with  those  of  animal  experiments, 
and  using  them  to  aid  in  explaining  the  occurrences  after  gastro- 
jejunostomy for  non-obstructive  chronic  ulcer,  it  must  be  remembered 
that  in  the  one  the  stomach  was  healthy,  in  the  other  diseased.  To 
settle  the  question  a  series  of  X-ray  examinations  is  needed,  taken 
immediately  after  operation  and  at  intervals  until  the  ulcer  has  healed. 
I  believe,  from  the  few  cases  I  have  examined  with  the  screen,  that 
after  gastro-jejunostomy  for  chronic  ulcer  the  food  passes  out  by  the 
anastomotic  opening,  owing  to  the  presence  of  pyloric  spasm,  but 
that  when  the  ulcer  has  healed  this  aperture  may  be  no  longer  used, 
though  by  remaining  as  a  safety-valve  it  prevents  an  ulcer  from 
again  becoming  chronic. 

Bolton's  experiments  have  proved  the  importance  of  impaired 
motility  in  preventing  the  healing  of  ulcers. 

After  gastro-jejunostomy  the  total  acidity  of  the  gastric  contents 
is  lowered  (Willcox,  Paterson).  This  is  due  partly  to  the  escape  of 
bile  or  pancreatic  juice  into  the  stomach,  and  also  in  all  probability, 
as  pointed  out  by  Paterson,  to  the  earlier  secretion  of  pancreatic  juice 
and  consequent  earlier  diminution  of  gastric  secretion  due  to  the 
presence  of  an  acid  fluid  in  the  jejunum. 

The  beneficial  effect  of  gastro-jejunostomy  in  allowing  ulcers  to 
heal  is  twofold.  In  the  first  place,  by  more  rapid  emptying  of  the 
stomach  it  prevents  irritation  of  the  ulcer  ;  secondly,  it  leads  to 
diminution  of  HC1.  That  the  first  is  a  factor  is  shown  by  the  imme- 
diate relief  given  by  operation  :  it  is  no  uncommon  thing  to  find  a 
patient,  a  week  after  gastro-jejunostomy,  able  to  eat  solid  food  ;  it  is 
inconceivable  that  a  large  ulcer  should  be  healed  in  a  few  days  by 
diminution  of  gastric  acidity  only. 

That  the  operation  has  no  evil  effects  on  nutrition  is  proved  by 


COMPLICATIONS   OF   GASTROJEJUNOSTOMY     p 

the  normal  growth  and  developmenl  of  children  who  have  had  gastro- 
jejunostomy done  in  infancy  for  infantile  pyloric  stenosis.  It  has 
been  shown  by  the  investigations  of  Paterson  on  the  absorption  oi 
Eat  and  of  nitrogen  from  a  mixed  diet  after  gastrojejunostomy,  thai 
the  percentage  absorbed,  although  very  Blightly  below  the  average, 

IS  within  the  limits  observed  in   healthy  individuals. 

Complications. — The  following  complications  may  occur  after 
gastrojejunostomy,  the  majority  being  due  to  faulty  technique:  (1) 
Haemorrhage  ;  (2)  regurgitant  vomiting  ;  (3)  peptic  ulcer  of  jejunum  ; 
(4)  intestinal  obstruction  (internal  hernia)  ;  (5)  diarrhoea;  (f>)  con- 
traction of  opening. 

1.  Several  cases  have  been  recorded  recently  in  which  severe 
haemorrhage  has  followed  the  operation  of  gastrojejunostomy  :  in 
one  fatal  case  the  source  of  the  bleeding  was  discovered  to  be  a  vein 
in  the  gastric  mucous  membrane.  This  has  led  some  to  advocate 
the  abandonment  of  the  use  of  clamps  during  the  operation,  on  the 
ground  that  they  prevent  the  surgeon  from  seeing  vessels  that  may 
be  bleeding;  others  advise  that  the  clamps  be  loosened  after  the 
posterior  row7  of  stitches  has  been  inserted.  Haemorrhage  is  due  to 
faulty  application  of  the  inner  suture,  probably  in  that  it  fails  to 
penetrate  all  the  coats  of  the  stomach  at  one  spot ;  this  may  easily 
occur  if  too  much  or  too  little  mucous  membrane  is  removed.  It  can 
be  prevented  by  careful  suturing. 

The  only  instance  of  severe  haematemesis  that  has  occurred  in  my 
cases  was  some  years  ago,  before  I  used  clamps.  Three  hours  after 
operation  the  patient  vomited  about  a  pint  of  blood,  but  no  untoward 
result  followed. 

The  haemorrhage  may  in  a  few  cases  come  from  the  ulcer  itself  : 
this  may  be  avoided  by  infolding  the  ulcer. 

2.  Regurgitant  vomiting  (vicious  circle).— This  is  rarely  met 
with  after  the  modern  no-loop  operation.  It  is  due  in  most  cases  to 
faulty  technique.  In  the  early  days  of  gastrojejunostomy  it  was  a 
much-dreaded  and  very  fatal  complication. 

Various  theories  were  at  one  time  put  forward  with  regard  to  it. 
At  first  it  was  thought  to  be  due  to  the  presence  of  bile  in  the  stomach, 
but  this  has  been  disproved  both  by  animal  experiment  and  as  the 
result  of  operation.  In  a  case  of  ruptured  duodenum,  Moynihan  closed 
both  ends  and  joined  the  jejunum  to  the  stomach.  All  the  bile  and 
pancreatic  juice  had  to  pass  through  the  stomach,  but  no  vomiting 
ensued. 

It  is  the  result  of  intestinal  obstruction,  and  is  due,  in  most  c 
to  leaving  a  loop  of  jejunum  between  the  flexure  and  the  anastomosis. 
This  becomes  "bile-logged,"  and  the  fluid,  unable  to  escape, 
backwards  into  the  stomach.     In  other  cases  the  weight  of  the  loop 


4M      THE  STOMACH  AND  DUODENUM 

may  cause  a  kink  at  the  anastomosis.  In  a  few  cases  a  kink  may 
obstruct  the  efferent  opening,  or  adhesions  obstruct  the  jejunum 
beyond.  As  has  been  pointed  out  by  Paul,  Stanmore  Bishop,  and 
myself,  regurgitant  vomiting  is  liable  to  arise  not  only  from  faults- 
technique  but  also  from  operation  upon  unsuitable  cases,  particularly 
cases  of  atonic  dyspepsia.  The  only  two  severe  cases  of  regurgitant 
vomiting  I  have  met  with  were  in  cases  in  which  no  lesion  was 
demonstrated  in  the  stomach ;  both  recovered.  These  are  cases 
which  would  not  now  be  treated  by  operation. 

Symptoms. — Vomiting  after  gastrojejunostomy  is  uncommon ;  in 
most  cases  no  vomiting  at  all  takes  place.  When,  from  the  presence 
of  adhesions  or  from  trouble  in  administering  the  anaesthetic,  operation 
proves  to  be  difficult,  copious  bilious  vomiting  may  occur,  but  passes 
off  within  forty-eight  hours  ;  this  I  am  in  the  habit  of  referring  to 
as  "  paralytic."  If  it  persists  longer  it  is  probably  truly  regurgitant. 
In  the  typical  case  vomiting  does  not  develop  for  several  days  after 
operation.  Bilious  vomiting  may  first  appear  many  weeks  or  months 
later,  although  it  is  unusual  to  see  it  after  the  third  week. 

In  severe  cases,  large  quantities  of  bile-stained  fluid  are  vomited 
once  or  twice  a  day.  The  vomit  gushes  up  with  very  little  effort, 
and  as  a  rule  contains  no  food.  Emaciation  is  rapid,  and  death  occurs 
unless  relief  is  given.  These  cases  are  rare  with  modern  methods  of 
operating. 

In  less  severe  cases,  vomiting  of  a  similar  nature  occurs  at  irre- 
gular intervals.  In  still  slighter  cases  there  is  regurgitation  of  small 
quantities  of  bilious  fluid.  In  the  slight  cases  the  patient  may  put 
on  weight  and  obtain  complete  relief  from  the  symptoms  for  which 
the  operation  was  performed. 

Treatment. — Lavage  should  be  employed  once  or  twice  a  day,  and 
continued  until  the  passage  of  the  stomach-tube  reveals  no  excess  of 
fluid  in  the  stomach.  In  the  severe  cases  coming  on  soon  after  opera- 
tion, if  lavage  does  not  speedily  relieve,  further  operation  must  be 
undertaken.  If  a  loop  has  been  left,  it  is  usually  found  distended. 
Entero-anastomosis  between  the  afferent  and  efferent  limbs  should 
be  performed,  or  the  afferent  limb  divided  and  implanted  into  the 
efferent  below  the  anastomosis  (Roux's  operation).  It  may  happen 
that  neither  is  possible,  there  being  no  loop  ;  in  these  cases  entero- 
enterostomy  should  be  carried  out  by  the  method  employed  by  Finney 
for  gastro-duodenostomy  (p.  418),  or  a  communication  made  with  the 
second  part  of  the  duodenum. 

If  the  operation  was  performed  for  symptoms  only,  and  no  lesion 
of  stomach  found,  the  anastomosis  should  be  excised  and  the  con- 
tinuity of  intestine  re-established. 

3.  Peptic  jejunal  ulcer. — Ulceration  of  the  jejunum  after  gastro- 


COMPLICATIONS   OF   GASTROJEJUNOSTOMY     p, 

jejunostomy  is  an   uncomm sondition.     It   was  firsl   described  by 

Braim  in  L889  ;  twenty  years  later,  Paterson  was  able  to  publish  the 
result  of  Ins  investigation  of  52  certain  and  II  doubtful  cases.     Since 

that    date,  cases    have    heen    recorded    |>\-    Battle,  IdOD    and    Moivau    (2), 

Maylard,  Rubritius,  Blorschutz ;  and  I  have  had  two  under  my  care. 

The    first .   a    male  aged  47,   had    had    a    |><  --1  <i  e  .1    gastro  jejunostomy  with 

snteio-anastomosis  performed  by  another  surgeon  three  years  previously. 
Owing  to  the  recurrence  of  symptoms,  I  explored  and  found  a  chronic  nicer 
in  the  jejunum   immediately  opposite  to  the  opening  in  the  stomach.     In 

the  other  case  J   had    performed    posterior    no  loop    gastro-jejunostom 
months  previously,  in  a  man  of  39,  for  chronic  duodenal  ulcer.     He  was 
suddenly  seized  with  hsematemesis.     At  the  operation  I   found   a  typical 
round  chronic  ulcer  on  the  anterior  surface  of  the  jejunum,  an  inch  distal 
to  the  anastomosis.     I  excised  the  ulcer,  and  he  has  remained  well. 

It  is  impossible  to  estimate  the  frequency  with  which  this  com- 
plication occurs,  but  it  is  probably  not  more  than  1  per  cent. 

The  ulcer  is  usually  solitary,  and  resembles  in  every  respect  that 
met  with  in  the  stomach  or  duodenum.  It  may  be  of  the  acute  or 
the  chronic  type,  and  is  usually  situate  in  the  efferent  limb,  within 
an  inch  of  the  anastomotic  opening.  Occasionally,  ulceration  may  be 
present  at  the  site  of  anastomosis,  involving  both  stomach  and  duo- 
denum ;  to  this  type  Paterson  gave  the  name  of  gastro-jejunal.  This 
latter  type  appears  to  be  the  direct  result  of  operation  in  most  cases, 
and  is  often  associated  with  infection  of  an  inner  silk  suture  ;  non- 
absorbable material  should  not  be  used  for  this  stitch. 

Jejunal  ulcers  have  been  met  with  most  often  in  men,  and  have  not 
been  recorded  after  gastrojejunostomy  for  carcinoma  of  the  stomach ; 
but  in  one  case,  published  by  Einar  Key,  death  occurred  from  the 
perforation  of  a  jejunal  ulcer,  twenty  days  after  partial  gastrectomy 
with  anterior  gastrojejunostomy  had  been  performed  for  carcinoma 
of  the  stomach. 

Ulcer  has  been  met  with  after  all  forms  of  gastrojejunostomy, 
anterior  and  posterior,  with  or  without  a  loop,  or  entero-anastomosis 
and  "  en'  Y  "  (Roux's  operation).  It  is  undoubtedly  met  with  most 
often  after  the  Y-type  of  operation  (including  the  loop  operations  in 
wdiich  entero-anastomosis  has  been  performed),  and  after  anterior 
loop  operations.  It  is  most  uncommon  after  the  posterior  no-loop 
operation.  Paterson  stated,  in  1909,  that  so  far  no  instance  had  been 
recorded.  Moynihan  states  that  it  may  occur  after  the  posterior  no- 
loop  method  ;   the  case  I  have  recorded  bears  this  out. 

Its  frequency  after  the  anterior  operation  is  undoubted  ;  thus, 
Rubritius  has  recorded  its  occurrence  in  3  out  of  33  cases  of  anterior 
gastro- jejunostomy  performed  by  him  ;  it  did  not  occur  among  the 
45  posterior  operations.     Mayo  Robson  observed  it  once  among  30 


416  THE   STOMACH   AND   DUODENUM 

anterior  operations,  but  not  once  after  300  posterior  operations;  W.  J. 
Mayo,  not  once  in  715  operations. 

The  ulcer  appears  to  be  due  to  a  continuance  of  the  conditions 
that  lead  to  the  formation  of  the  original  gastric  ulcer  (p.  341),  the 
frequency  of  this  complication  after  the  Y  and  long-loop  type  of 
operations  being  due  to  their  less  efficient  action  in  diminishing  hyper- 
acidity and  to  the  action  of  the  gastric  juice  on  mucous  membrane 
unused  to  it.  Hyperacidity  is  frequently  present  (in  13  out  of  18 
cases,  Paterson). 

Those  cases  in  which  the  ulceration  occurs  at  the  anastomotic 
margin  are  probably  due  to  infection. 

Symptoms. — These  may  arise  at  any  time  from  a  few  days  to  years 
after  the  operation  ;  the  shortest  recorded  interval  has  been  two 
days,  and  the  longest  eight  years.  In  more  than  half  the  cases, 
symptoms  appear  within  a  year,  in  75  per  cent,  within  two  years, 
of  operation. 

The  cases  fall  into  three  groups — (i)  those  with  acute  symptoms  of 
perforation  or  haemorrhage  ;  (ii)  those  with  symptoms  suggesting  recur- 
rence of  the  original  trouble  ;  (iii)  those  with  perforation  into  the  colon. 

i.  Perforation  may  occur  within  a  few  days  of  operation  ;  as  a  rule 
it  is  about  a  year  later,  but  it  has  taken  place  five  years  after  opera- 
tion. The  patient  in  the  interval  has  usually  been  quite  free  from 
symptoms.  The  ulcer  may  be  either  an  acute  or  a  chronic  one.  In 
two  instances  (Battle,  Maylard)  after  anterior  gastroenterostomy, 
the  patient  suffered  on  two  occasions  from  perforation  of  a  jejunal 
ulcer.     Operation  in  both  patients  on  both  occasions  was  successful. 

The  symptoms  resemble  those  of  perforated  gastric  ulcer,  and  the 
differential  diagnosis  is  impossible. 

ii.  About  two-thirds  of  all  the  recorded  cases  fall  into  this  group. 
In  some,  particularly  after  the  anterior  operation,  an  abdominal  tumour 
develops  as  the  result  of  a  subacute  perforation  and  adhesions  to  the 
abdominal  wall.  The  swelling  is  usually  in  the  region  of  the  upper 
left  rectus  muscle.     Occasionally  a  jejunal  fistula  forms. 

iii.  In  8  recorded  cases  (Kaufmann,  Czerny,  Gosset,  Herczel, 
Cackovic,  Morschutz,  Lion  and  Moreau  2),  perforation  took  place 
into  the  transverse  colon,  and  in  1  case  (Kaufmann)  there  was  a 
gastro-colic  fistula  with  closure  of  the  gastrojejunostomy  opening. 
In  all  the  gastrojejunostomy  was  posterior,  in  one  (Lion  and  Moreau) 
Roux's  operation  was  performed.  The  ulcer  is  usually  chronic,  and 
symptoms  of  pain  and  discomfort  after  food  are  followed  by  vomiting 
of  faecal  material  or  of  vomit  with  a  faecal  odour.  In  many  cases 
undigested  food  is  passed  soon  after  it  is  taken. 

Treatment. — This  should  be  preventive.  The  operation  should  be 
of  the  no-loop  type  and,  if  possible,  posterior.     If  from  the  presence 


COMPLICATIONS   OF   GASTROJEJUNOSTOMY   4*7 

of  adhesions  this  is  impossible,  then  the  anterior  ao-loop  operation 
that  1  have  described  should  be  done  (p.  U)8).  The  anastomotic 
opening  should  be  large.  The  appendix  .should  be  removed  if  the 
condition  of  the  patient  permits.  Treatment  musl  uot  cease  with 
the  performance  of  gastro-enterostomy  (p.  353). 

When  perforation  has  occurred,  laparotomy  with  immediate 
suture  must  be  carried  out.  This  is  the  life-saving  measure  ;  but  the 
causes  leading  to  the  production  of  the  ulcer  may  still  be  acting,  for 
in  several  eases  after  the  successful  suture  of  a  perforation  another 
has  occurred  at  a  later  date.  The  condition  of  the  stomach  and  the 
size  of  the  anastomotic  opening  are  to  be  investigated;  if  the  latter 
is  too  small  or  has  closed,  the  defect  must  be  remedied  if  possible. 
The  appendix  should,  if  possible,  be  removed.  During  recovery, 
means  should  be  taken  to  prevent  hyperacidity ;  and  if  the 
operation  is  found  to  have  been  faulty,  rectification  of  this  should  be 
di -cussed.  In  the  second  group  of  causes,  prolonged  medical  treat- 
ment should  be  tried.  If  this  fails,  operation  should  be  performed, 
the  anastomosis  excised,  and  a  fresh  no-loop  operation  done  or  both 
Limbs  implanted  into  the  stomach. 

In  the  third  group,  the  viscera  should  be  separated,  the  opening 
in  the  colon  closed,  and  a  fresh  gastrojejunostomy  performed. 

4.  Intestinal  obstruction After  posterior  operations,  internal 

hernia  has  occurred  into  the  lesser  sac  (Moynihan,  Hartmann,  Ashurst). 
This  is  to  be  prevented  by  suturing  the  edge  of  the  opening  in  the 
mesocolon  to  the  stomach. 

Strangulation  has  taken  place  beneath  the  loop  formed  in  anterior 
gastrojejunostomy,  more  rarely  in  posterior.  Barker  recorded  a  case 
following  the  latter  in  which  nearly  the  whole  of  the  small  intestine 
had  passed  through,  and  had  in  addition  become  twisted  on  itself. 

In  anterior  loop  gastro-enterostomy  the  colon  may  be  compressed. 

5.  Diarrhoea  occasionally  occurs  after  gastrojejunostomy.  It 
has  been  noticed  most  often  in  cases  of  carcinoma.  Its  causation  is 
unknown.  As  a  rule  it  soon  passes  off,  but  has  been  fatal.  In  one 
case  which  proved  fatal,  Kelling  could  discover  no  cause  post  mortem. 

6.  Contracture  and  closure  of  the  opening  is  due  to  gastro- 
jejunal  ulceration.  It  more  often  followed  operation  performed  with 
the  aid  of  Murphy's  button,  with  its  necessary  ulceration  of  the 
margins  of  the  opening.  If  healing  by  first  intention  takes  place., 
closure  will  not  occur.  The  inner  layer  of  suture  should  be  of 
absorbable  material  to   avoid  late  infection. 

Anterior  versus   posterior    gastro-enterostomy. — The 

posterior    gastrojejunostomy   is    the    operation    of    choice,    for    the 

following    reasons :     1.  It    affords    better    drainage   of   the   stomach, 

inasmuch  as  the  posterior  is  also  the  inferior  wall.     2.  A  higher  part 

■lb 


4i8 


THE   STOMACH   AND   DUODENUM 


of  the  jejunum  can  be  used  for  anastomosis,  and  thus  less  of  this 
important  part  of  the  intestine  is  looped  up  and  thrown  out  of  use. 
3.  There  is  no  necessity  for  the  formation  of  a  loop  with  its  attendant 
dangers  of  internal  hernia  and  obstruction,  and  therefore  symptoms 
of  the  so-called  "  vicious  circle  "  or  regurgitant  vomiting.  4.  There 
is  less  danger  of  the  formation  of  a  peptic  ulcer. 

If  the  anterior  method  be  carried  out  without  a  loop  in  the  way 

I  have  described  the   results 
/  "*X> .  are    as  good    as  in    the   pos- 

N  ^  terior,  but,  as  it  is  more  diffi- 

cult of  employment  and  alters 
the  anatomical  relation  of 
parts  more,  it  should  not  be 
employed  where  the  posterior 
operation  is  possible.  (Fig. 
393.) 

Gastro-Duodenostomy 

This  operation  is  rarely 
employed,  except  as  Finney's 
modification, whichis  explained 
by  Fig.  394.  It  is  useful  in 
cases  of  fibrous  stricture  of 
the  pylorus  and  certain  cases 
of  gastroptosis. 

JEJUNOSTOMY 

This  should  be  done  by 
Mayo  Robson's  method.  A 
loop  of  jejunum  is  taken  as 
high  as  possible,  allowing 
sufficient  length  to  reach  the 
abdominal  wall  easily.  The 
two  arms  of  the  loop  are 
short-circuited  by  lateral  anastomosis.  An  opening  is  made  at  the 
top  of  the  loop,  then  a  No.  12  catheter  is  inserted  and  passed  for 
3  in.  into  the  distal  limb  of  the  loop,  and  the  margin  of  the  open- 
ing inverted  by  two  purse-string  sutures.  The  apex  of  the  loop 
is    fixed   to  the  skin. 


Fig.  394. — Finney's  operation  of 
gastro-duodenostomy. 


BIBLIOGRAPHY 

Brinton.  Lectures  on  the  Diseases  of  the  Stomach,  2nd  edit.     London,  1864. 
Deaver,  J.  B.,  and  A.  P.  C.  Ashurst,  Surgery  of  the  Upper  Abdomen,  vol.  i.    1909. 
Fenwick,  W.  Soltau,  Cancer  and  other  Tumours  of  the  Stomach  (1902);  and   Ulcer 
of  the  Stomach  and  Duodenum  and  its  Consequences  (1900). 


BIBLIOGRAPHY  419 

Habershon,  S.  H.,  Diseases  of  tht  Stomach,     1909. 
Moynihan,  B.  G.  A.,  Duodenal  Ulcer.     L910. 
Osier  and  McCrae,  Cancer  of  the  Stomach,     1900. 
Paterson,  Herbert  J.,  Gastric  8uraery.     L906. 

Robson,  A.  W.  M..  and  B.  G.  A.  Moynihan,  Dt*  ox  !  0/  the  8tomach  and  tin  h 
Treatment,  2nd  '''lit.     1904. 

An  \i"MY    \m>   Phi  molog* 
Barclay,  A.  E.,  Proc.  Roy.  8oc  Med.,  Feb.,  1909;   Brit.  Med.  Journ.,  1910,  ii. 
Cannon,  .  l»wr.  Joum.  Phys.,  1898,  i.  369. 
Dobson,  J.  F..  and  J.  K.  Jamieson,  Lancet,  1907,  i.  1061. 
Gray,  H.  M.  W.,    Lancet,   L908,  ii.  224;    1910,  ii.   1610.     Also  correspondence  in 

numbers  for  Dec.  10,  17,  22,  31. 
Hertz,    A.  F.,   Brit.  Med.   Joum.,  1908,   i.    130;    1911,  i.  477:     Quarterly    J< 

M,d.,  July,  1910. 

Clinical  Examination,  etc. 

Head,  H..  Brain,  L893,  xvi.  1  ;    1894,  xvii.  339. 

Head.  Rivers,  and  Sherren,  Bruin.  Nov.,  1905. 

Hertz,  A.  F.,  The  Sensibility  of  the  Alimentary  Canal.     191 1- 

Hill,  W.,  Brit.  Med.  Joum.,  1911,  Oct,  28. 

Lennander,  Mitt.  a.  d.  Grenzgeb.  d.  Med.  u.  Chir.,  Bd.  x.,  Hefte  1,  2;  Bd.  xv., 
Heft  5;    Bd.  xvi,  Heft  1  ;    Deuts.  Zeits.  f.  Chir.,  Nov.,  1905. 

Mackenzie,  James,  Brit.  Med.  Joum.,  June  23,  30,  1906  ;  Symptoms  and  their  Inter- 
pretation, 1909. 

Panton,  P.  N.,  and  H.  L.  Tidy,  "  On  the  Analysis  of  Gastric  Contents,"  Quarterly 
Journ.  Med.,  July,  1911,  vol.  iv.,  Xo.  16. 

Sherren,  James,  Clin.  Joum.,  June  28,  1905. 

Willcox,  W.  H.,  Med.  Soc.  Trans.,  xxxi.  229  ;    Lancet,  1910,  i.  1119. 

Malformations 
Barnard,  H.  L.,  contributions   to  Abdominal  Surgery,  edited  by  James  Sherren, 

p.  144. 
Clogg,  H.  S.,  Lancet,  1904,  ii.  1770. 
Keith,  Arthur,  Brit.  Med.  Joum.,  1910,  i.  303. 
Kuliga,  Beitr.  z.  path.   Anat.,  1903,  xxxiii.  481. 

Infantile  Stenosis 

Burghard,  F.  F.,  Trans.  Clin.  Soc,  xl.  122. 

Cautley  and  Dent,  Med.- Chir.  Trans.,  1903,  lxxxvi.  471  ;    Brit.  Med.  Journ.,  1906, 

ii.  939. 
Hutchison,  Robert,  Brit.  Med.  Journ.,  1910,  ii.  1021. 
Nicoll,  J.  H.,  Gla.sg.  Med.  Journ.,  1906,  lxv.  253. 
Stiles,  Harold,  Brit.  Med.  Journ.,  1906,  ii.  943  ;  1909,  ii.  752. 

Still,  G.  F„  Lancet,  March  11,  1905  ;    Common  Disorders  and  Diseases  of  Childhood, 
Sutherland,  G.  A.,  Trans.  Clin.  Soc,  xL  98. 

Thomson,  John,  Clinical  Examination  and  Treatment  of  Sick  Children. 
Voelcker.  Arthur,  Trans.  Clin.  Soc,  xL  108. 
Willcox,  W.  H.,  and  R.  Miller,  Lancet,  Dec.  14,  1907. 

Hour-Glass  Stomach 
Delamere  et  Dieulale,  BuE.  et  Mem.  de  la  Soc.  Anat.,  Pari?,  1906,  viii.  407. 
Downes,  W.  A.,  Ann.  of  Surg.,  1909,  ii.  552.  646. 
Moynihan,    B.   G.  A.,   Med. -Chir.   Trans.,  lxxxvii.  143:  Brit.  Med.   Joum.,  1904, 

i.  414. 
Veyrassat,  Rev.  de  Chir.,  Aug.,  Sept.,  Dec,  1908,  xxxviii.  269,  403,  761. 
Wolfer,  Beitr.  z.  Uin.  Chir.,  1895,  xiii.  221. 


420  THE   STOMACH   AND   DUODENUM 

Acute  Dilatation  of  the  Stomach 
Box,  C.    R.,   and   Cuthbert  Wallace,  Cltn.  Soc.  Trans.,  1898,   xxxi.  241  ;   Lancet, 

1901,  ii.   1259;    1911,  ii.  214. 
Laffer,  Walter  B.,  Ann.  of  Surg.,  1908,  i.  390. 
Nicholls,  A.  G.,   Internal.  Clin.,  1908,  iv.  80. 
Thomson,  H.  Campbell,  Acute  Dilatation  of  the  Stomach.     1902. 

Injuries  of  the  Stomach  and  Duodenum 
Berry,  J.,  and   Paul  L.  Giuseppi,  Proc.  Roy.  Soc.  Med.,  Surgical  Section,  Oct.  13. 

1908,  p.  41. 
Forgue  et  Jeanbrau,  Rev.  de  Chir.,  1903,  xxviii.  285. 
Meerwein,  Beitr.  z.  klin.  Chir.,  1907,  liii.  496. 

Chronic  Gastric  and  Duodenal  Ulcer 
Bolton,  Charles,  Med.  Soc.  Trans.,  xxxi.  249  ;    Proc.  Roy.  Soc,  1904,  lxxiv.  135  ; 

1907,  B  lxxix.  53  ;  1910,  B  lxxxii.  233 ;  Brit.  Med.  Journ.,  1910,  i.1221,  ii.  1963. 
Dawson,  Sir  Bertrand,  Med.  Soc.  Trans.,  1902,  xxvi.  55  ;  Brit.  Med.  Journ.,  May  9, 

1908  ;    Lancet,  1911,  i.  1124. 
English,  T.  Crisp,  Med.- Chir.  Trans.,  1904,  lxxxvii.  27. 
Eve,  Sir  Frederic,  Lancet,  1908,  i.  1822. 
Fenwick,  W.  Soltau,  Lancet,  1910,  i.  706. 
Kindl,  Beitr.  z.  klin.  Chir.,  Bd.  lxiii.,  Heft  1. 
Mayo,  W.  J.,  Ann.  of  Surg.,  1908,  i.  885  ;   1911,  ii.  313. 
Miles,  Alexander,  Edin.  Med.  Journ.,  1906,  pp.  106,  223. 
Miller,  Charles,  Arch.  Path.  Inst.  London  Hospital,  1906,  i.  39. 
Moullin,  C.  Mansell-,  Lancet,  1910,  ii.  993  ;   Med.- Chir.  Trans.,  xc.  275. 
Moynihan,  B.  G.  A.,  Ann.  of  Surg.,  1908,  i.  873  ;    Brit.  Med.  Journ.,  1910,  i.  241  ; 

Med.-Chir.  Trans.,  1906,  lxxxiv.  471  ;   Proc.  Roy.  Soc.  Med.,  Surgical  Section, 

Dec.  14,  1909,  p.  69;   Jan.  11,  1910,  p.  97  (discussion). 
Paterson,  H.  J.,  Lancet,  1910,  i.  708  ;  1911,  i.  97. 
Robson,  A.  W.  Mayo,  Brit.  Med.  Journ.,  1907,  i.  248  ;    Med.-Chir.  Trans.,  1907, 

xc.  228,  and  discussion  ;    Med.  Soc.  Trans.,  1902,  xxvi.  72,  and  discussion. 
Rodman,  W.  L.,  Journ.  Amer.  Med.  Assoc,  1908,  i.  165. 
Sherren,  James,  Trans.  Clin.  Soc,  1907,  xl.  156  ;  Med.  Press,  April  7  and  14,  1909; 

Lancet,  April  1,  1911  ;  Lond.  Hosp.  Gaz.,  Oct.,  1911. 
Smith,  Maynard,  Lancet,  1906,  i.  895. 
White,  W.  Hale,  Lancet,  1906,  ii.  1189  ;  Med.-Chir.  Trans.,  xc.  215  ;    Lancet,  1910, 

i.   1819. 

Carcinoma  of  the  Stomach 
Braun,  Deuts.  Zeits.  f.  Chir.,  1907,  lxxxvii.  275. 
Goldschwend,  von  Langenbecks  Archiv,  Bd.  lxxxviii.,  Heft  1. 
Groves,  E.  W.  Hey,  Brit.  Med.  Journ.,  1910,  i.  366. 
Janeway  and  Green,  Ann.  of  Surg.,  1910,  ii.  67. 
Kocher,  Mitt:  a.  d.  Grenzgeb.  d.  Med.  u.  Chir.,  Bd.  xx.,  Heft  5. 
Mayo,  W.  J.,  Journ.  of  Amer.  Med.  Assoc,  1910,  liv.  608. 
Moullin,  C.  Mansell-,  Lancet,  1910,  i.  415. 
Moynihan,  B.  G.  A.,  Trans.  Clin.  Soc.  Lond.,  1906,  xxxix.  84  ;    Brit.  Med.  Journ., 

1906,  i.  370  ;  1909,  i.  830. 
Paterson,  H.  J.,  Brit.  Med.  Journ.,  1910,  ii.  953. 
Poncet,  Delore,  et  Leriche,  Gaz.  des  Hop.,  1909,  35. 
Robson,  A.  W.  Mayo,  Med.-Chir.  Trans.,  VMM,  xc.  232. 
Sherren,  James,  Clin.  Journ.,  Oct.  19  and  26,  1910  ;   Brit.  Med.  Journ.,  June  24, 

1911. 
Wilson  and  MacCarty,  Amer.  Journ.  Med.  ScL,  Dec,  1909. 

Carcinoma  of  the  Duodenum 
Coffey,  R.  C,   Ann.  of  Surg.,  1909,  ii.  1238. 
Desjardins,  Rev.  de  Chir.,  June  10,  1907. 


BIBLIOGRAPHY  421 

Kausch,  Z'liimlhi.  j.  Ghir.,  L909,  p.  L351. 

Mayo,  W.  J.,   Ann.  of  8urg„  L907,  ii.  890. 

Rolleston,  Diseases  of  Intestim  and  Peritoneum  (Nothnagel,  English  translation), 

p.  140, 
Sauve,  Rev.  de  Chir.,  Feb.  10,  1908. 
Wendel,   Arch.  /.  Klin.  Chir.,  1907,  Kwiii.  835. 

Sarcoma  of  the  Stomach 
von  Eiselsberg,  Arch.  /.  Uin.  Chir.,  1S'.)7,  xl.  599. 
Howard,  Journ.  of  Amer.  Med.  Assoc,  July,  1902. 
Maylard,  A.  E.,  and  J.  Anderson,   Ann.  of  Surg.,  1910,  ii.  ."ion. 
Salaman,  R.  N„  Trans.  Path.  8oe.  Land.,  1904,  lv.  part  iii.  324. 
Sherren,  James,  Brit.  Med.  Journ.,  1911,  ii.  593. 
Yates,    Ann.  of  Surg.,  1906,  ii.  599-1  i:!'.i. 

Plastic  Linitis 
Jonnesco  el  Grossman,^ Rev.  de  Chir.,  1908,  xxxvi.    18. 
Leith,  R.  F.,  AUbutt's  System  of  Medicine,  1907,  iii.  437. 
Lyle,  H.  H.  M.,   Ann.  of  Surg.,  1911,  ii.  (>2.->. 
Thomson,  Alexis,  Brit.  Med.  Journ.,  1910,  ii.  949. 

Gastro-  Je  jun  ostomy 
Brenner,  Wien.  Uin.   Work.,  1892,  v.  375. 

Moullin,  C.  Mansell-,  Brit.  Med.  J  num.,  1910,  ii.  955;    Lancet,  1905,  i.  65. 
Moynihan,  G.  B.  A.,  Brit.  Med.  Journ.,  1908,  p.  1092. 
Paterson,  Herbert  J.,  Lancet,  1907,  ii.  815. 
Pers,  Zentralbl.  f.  Chir.,  1909,  p.    1417. 

Jejunal  Ulcer 
Connell,  Surg,  of  Gyn.  and  Obstet.,  1908,  p.   139. 
Lion  et  Moreau,  Rev.  de  Chir.,  xxix.  5. 
Moynihan,  G.  B.  A.,   Universal  Med.  Rec,   1912,  i.  11  ;    Surg.,  Gyn.,  andr  Obstet., 

June.  I'll  17  ;  Aim.  of  Surg.,  1908,  i.  1051. 
Paterson,  H.  J.,  Ann.  of  Surg.,  1909,  ii.  367. 
Robson,  A.  W.  Mayo,  Med.-Chir.  Trans.,  lxxxvii.  339. 
Rubritius,  H.,  Beitr.  z.  Uin.  Chir.,  1910,  lxvii.  222. 
van  Roojen,  Arch.  f.  Uin.  Chir.,  1910,  xci.  380. 


THE    INTESTINES 

By  ALEXANDER  MILES,  M.D.,  F.R.G.S.Ed. 

For  the  purposes  of  this  article,  the  intestines  may  be  taken  to 
include  that  portion  of  the  alimentary  canal  which  extends  from  the 
termination  of  the  duodenum  at  the  duodeno-jejunal  junction  to  the 
lower  end  of  the  pelvic  colon,  where  it  becomes  continuous  with  the 
rectum.  Although  the  duodenum  belongs  anatomically  to  the  small 
intestine,  its  surgical  associations  are  with  the  stomach,  and  are 
considered  in  the  preceding  article.  The  affections  of  the  vermiform 
appendix  and  of  the  rectum  are  also  most  conveniently  described 
elsewhere  (pp.  537  and  658). 

ANATOMY 

The  small  intestine,  arbitrarily  divided  into  jejunum  and 
ileum,  is  about  20  ft.  in  length,  and  with  the  exception  of  the  first 
part  of  the  jejunum  and  the  terminal  part  of  the  ileum,  which  are 
fairly  constant  in  their  position,  the  numerous  coils  enjoy  a  wide 
range  of  mobility,  and  show  considerable  variation  in  their  disposition. 
As  a  rule,  however,  the  jejunum,  which  includes  the  first  8  ft.  of  the 
canal,  lies  towards  the  upper  and  left  part  of  the  cavity,  below  the 
level  of  the  stomach,  while  the  ileum,  about  12  ft.  in  length,  lies  in 
the  lower  and  right  regions.  Although  there  is  no  definite  point  of 
transition  between  the  two  portions,  in  the  living  subject  the  jejunum 
can  usually  be  distinguished  from  the  ileum  by  its  greater  width,  its 
thicker  and  more  vascular  walls,  its  brighter  colour,  and  the  more 
prominent  yellow  lines  formed  by  the  lacteals.  The  valvulse  conni- 
ventes  are  larger  and  more  closely  approximated  in  the  jejunum, 
while  the  Peyer's  patches  are  larger  and  more  numerous  in  the  ileum. 

The  arcades  formed  by  the  mesenteric  vessels  become  more  numerous 
as  we  pass  down  the  intestine,  while  the  vessels  entering  into  their 
formation  become  smaller  (Monks). 

The  mesentery  is  a  double  fold  of  peritoneum  which  connects 
the  small  intestine  to  the  posterior  abdominal  wall  along  a  line  6  or 
7  in.  in  length,  extending  from  the   left  side   of  the   second  lumbar 

422 


SURGICAL   ANATOMY 

vertebra  downwards  to  the  righl  iliac  fossa.  Between  its  layei 
conveyed  the  blood-vessels  intestinal  branches  ol  the  Buperior 
mesenteric  artery  and  vein;  the  lymphatics,  which  are  connected 
with  numerous  (40-150)  mesenteric  glands;  and  the  nerves  of  the 
superior  mesenteric  plexus,  derived  from  the  solar  plexus.  Some 
fibres  Erom  the  vagus  ultimately  reach  the  intestine.  The  bowel 
itself  is  enclosed  in  the  free  border  of  the  mesentery,  which  thus 
furnishes  it   with  its  serous  covering. 

The  ileo-caecal  junction. — The  opening  between  the  small 
and  the  large  intestine — the  ileo-caecal  orifice — is  guarded  by  the 
ileo-caecal  valve,  composed  of  two  crescentic  segments  enclosing 
a  slit-like  opening,  which,  when  the  caecum  is  distended,  is  closed  and 
prevents  regurgitation  of  its  contents  into  the  small  intestine.  In 
all  likelihood,  the  circular  fibres  of  the  lowest  part  of  the  ileum  form, 
as  in  some  animals,  a  true  muscular  sphincter.  A  short  distance 
below  the  valve,  the  vermiform  process  opens  into  the  caecum. 

The  large  intestine  extends  from  the  caecum,  which  occupies 
the  right  iliac  fossa,  to  the  beginning  of  the  rectum  in  the  pelvic  cavity. 
It  is  about  5i-  ft.  in  length  ;  its  widest  part  is  the  caecum,  which,  when 
distended,  has  a  diameter  of  about  3  in.,  and  from  this  it  gradually 
narrows  till,  at  the  lower  end  of  the  pelvic  colon,  it  is  only  about 
1-}  in.  in  diameter. 

When  the  abdomen  is  opened,  the  normal  colon  can  be  distinguished 
from  the  small  intestine  by  its  sacculated  appearance,  by  the  presence 
of  three  longitudinal  muscular  bands  running  along  its  surface,  and 
by  the  appendices  epiploieae  which  project  from  its  serous  covering. 
When  the  bowel  is  greatly  distended,  and  is  covered  with  inflammatory 
exudate,  it  may  be  difficult  to  distinguish  large  from  small  intestine. 

While  it  may  be  said  that  normally  the  colon  arches  round  the 
small  intestine,  the  coils  of  which  lie  within  the  concavity  of  its  curve, 
those  segments  of  the  bowrel  that  are  completely  enveloped  by  peri- 
toneum or  that  have  a  mesentery  are  subject  to  great  variations  in 
their  disposition.  The  caecum,  for  example,  instead  of  lying  in  the 
right  iliac  fossa,  may  be  found  in  the  right  lumbar  region,  even  as 
high  as  the  under  aspect  of  the  liver,  or  it  may  hang  down  into  the 
pelvic  cavity.  The  transverse  colon,  wdiich  normally  arches  across 
the  abdomen  in  the  upper  part  of  the  umbilical  region,  frequently 
dips  downwards  as  a  U-  or  V-shaped  loop,  reaching  sometimes  to 
the  pubes,  and  thus  increasing  the  sharpness  of  the  angles  at  the 
hepatic  and  splenic  flexures.  When  distended  with  gas,  it  may  rise 
in  front  of  the  stomach.  The  pelvic  colon  also  varies  considerably 
in  length  and  position.  It  may  form  a  short,  horseshoe-shaped  loop 
of  not  more  than  6  or  8  in.,  or  may  be  two  or  three  times  as  long, 
and  be  thrown  into  several  curves,  assuming  an  S-  or  <2-shape,  in 


424  THE   INTESTINES 

which  case  it  is  not  always  easy  during  an  operation  to  recognize 
the  direction  in  which  a  particular  part  is  running,  especially  if  the 
bowel  is  distended.  Being  provided  with  a  well-developed  mesentery, 
it  enjoys  a  wide  range  of  movement,  and  when  distended  it  may 
reach  any  part  of  the  abdominal  cavity. 

The  ascending  colon,  the  hepatic  and  splenic  flexures,  and  the 
descending  and  iliac  portions  are  more  constant  in  their  position, 
as  they  are  not  completely  enveloped  by  peritoneum,  and  are  to  some 
extent  fixed  to  the  posterior  abdominal  wall  by  areolar  tissue. 

Blood  supply. — The  caecum  and  appendix  are  supplied  by  the 
ileo-colic   branch    of   the    superior    mesenteric   artery,  the  ascending 
colon  by  the  right  colic,  and  the  transverse  by  the  middle  colic  branch  ■ 
of  the  same  trunk. 

The  descending  colon  receives  its  blood  from  the  left  colic,  and 
the  iliac  and  pelvic  colons  from  the  sigmoid  arteries,  branches  of  the 
inferior  mesenteric.     The  veins  correspond  to  the  arteries. 

Lymphatics. — The  lymphatics,  after  leaving  the  bowel,  pass 
in  the  mesocolon  to  different  groups  of  glands  lying  along  the  course 
of  the  branches  of  the  superior  and  inferior  mesenteric  arteries.  Their 
arrangement  has  been  studied  by  Jamieson  and  Dobson,  and  is  shown 
in  Fig.  395. 

PHYSIOLOGY    OF    THE    INTESTINE 

The  functions  of  the  intestine  are — (1)  to  carry  on  the  digestive 
processes  begun  in  the  stomach  ;  (2)  to  provide  for  the  absorption 
of  the  products  of  digestion ;  and  (3)  to  excrete  the  indigestible 
residue.  For  the  fulfilment  of  these  functions  the  intestine  is  endowed 
with  secretory  and  motor  activities,  and  in  addition  the  secretions 
of  the  liver  and  pancreas  are  poured  into  its  lumen.  The  various 
enzymes  act  on  the  proteins,  carbohydrates,  and  fats  of  the  food,  and 
transform  them  into  substances  that  are  capable  of  being  absorbed 
into  the  lacteals  and  blood  capillaries  of  the  villi.  The  intimate 
mixing  of  the  food  with  the  digestive  juices,  and  the  passage  of  the 
chyme  along  the  alimentary  canal,  are  effected  by  the  movements 
of  the  intestinal  wall.  Derangements  may  occur  in  the  secretory  or 
in  the  motor  activities,  or  in  both. 

One  other  factor  has  to  be  noted — the  decomposition  of  food- 
stuffs by  bacteria.  This  occurs  normally  in  the  intestine,  and  is 
probably  essential  for  health.  The  processes  consist  in  the  fermen- 
tation of  carbohydrates,  putrefaction  of  proteins,  and  conversion  of 
fats  into  lower  fatty  acids.  Some  evidence  has  been  brought  forward 
to  prove  that  disturbance  of  digestion  may  be  associated  with  changes 
in  the  characters  of  the  intestinal  bacteria. 

The  secretion  of  ferments  is  confined  to  the  small  intestine,  the 


PHYSIOLOGY 


liver,  and  the  pancreas,  and  in  the  small  intestine  mosl  of  the  absorp- 
tion takes  place.  At  the  lower  end  of  the  ileum,  bacterial  fermen- 
tation of  carbohydrates  begins.  In  the  large  intestine,  only  Bmall 
quantities  of  the   food-stuffs   are  absorbed,   but    water   is   absorbed 


Fig.  395.— Lymphatics  of  the  colon, 

(F)Ciu  tin-    Transactions  of  the  Royal  Society  of  Medicine.     By  courtesy  of  Mr.  J.  F.  Poison 
and  Professor  J amicson.     Reduced.) 

readily.  The  fermentative  and  putrefactive  processes  reacli  their 
maximum  in  the  csecum  and  ascending  colon,  in  which  also  digestion 
still  goes  on,  ferments  being  present  in  the  chyme  which  passes  through 
the  ileo-caecal  valve. 

The  secretory  and  absorptive  function. — While  de- 
rangements of  the  hepatic  and  pancreatic  secretions  have  direct 
surgical  bearings,  the  same  cannot  be  said  of  changes  in  the  succus 


426  THE   INTESTINES 

entericus.  We  know,  however,  that  if  more  than  one-third,  that  is, 
a  length  of  about  7  ft.,  of  the  small  intestine  is  excised,  digestion  and 
absorption  are  decreased  to  such  an  extent  as  to  lead  to  nutritional 
deficiency.  Absorption  is  also  much  impaired  in  stenosis  or  paralysis 
of  the  bowel,  as  the  result  partly  of  venous  stagnation  in  the  wall, 
and  partly  of  decomposition  of  the  contents  and  consequent  inflam- 
matory changes.  Decreased  absorption  in  the  colon  is  manifested 
chiefly  by  an  excess  of  water  in  the  faeces. 

The  effects  of  motor  disturbances  are  more  marked  in  surgical 
conditions,  and  for  this  reason  the  intestinal  movements  deserve 
mention  in  some  detail. 

Movements  of  the  Small  Intestine 

The  small  intestine  exhibits  several  varieties  of  movement,  the 
most  important  being  rhythmic  segmentation  movements  and  peristalsis. 
These  have  been  investigated  in  the  excised  gut,  in  ansesthetized 
animals  with  the  peritoneal  cavity  opened,  and  in  normal  subjects 
by  means  of  X-rays.  The  last  method  has  been  specially  elabor- 
ated by  Cannon,  and  his  results  have  been  confirmed  in  the  human 
subject  by  Hertz.  It  consists  in  giving  carbohydrate  and  protein 
food-substances  in  which  a  bismuth  salt  is  suspended,  and  examining 
the  shadows  cast  by  the  bismuth  on  the  fluorescent  screen. 

Rhythmic  segmentation. — Movements  of  rhythmic  seg- 
mentation, which  are  the  most  frequent,  are  designed  to  mix  the  food 
with  the  intestinal  secretions.  While  observations  are  being  made 
through  the  fluorescent  screen,  one  or  more  dark  cord-like  shadows 
are  seen  scattered  over  the  field.  These  represent  segments  of  the 
intestine  which,  for  the  time  being,  are  at  rest.  If  one  of  these  shadows 
is  watched,  it  will  be  observed  that,  following  on  this  period  of  rest, 
it  suddenly  shows  signs  of  activity,  and  definite  nodes  appear  at  regular 
intervals.  The  part  of  the  intestine  upder  observation  is  divided 
by  the  constrictions  into  "  segments,"  which  exist  for  a  brief  space 
of  time.  Then  each  segment  is  split  into  two  "  particles,"  and  by 
the  fusion  of  pairs  of  particles  from  adjoining  segments,  new  segments 
are  formed.  Scarcely  have  they  appeared  than  they  in  turn  are 
halved,  and  a  third  series  takes  their  place.  The  movements  of  seg- 
mentation occur  at  intervals  of  7  to  10  seconds  ;  hence,  within  half 
an  hour,  each  small  mass  of  food  will  have  been  divided  more  than 
200  times.  By  these  rhythmic  movements  of  segmentation,  without 
changing  its  position  in  the  intestine,  the  food  is  thoroughly  mixed 
with  the  digestive  juices,  and  brought  into  intimate  contact  with  the 
absorptive  folds  of  mucous  membrane.  In  addition,  the  rhythmic 
contractions  of  the  muscular  wall  pump  blood  from  the  submucous 
venous  plexuses,  and  empty  the  lacteals. 


MOVEMENTS   OF   SMALL   INTESTINE 

Peristalsis. — When  movements  of  segmentation  have  con- 
tinued f<>r  BOme  time,  tin-  food  mows  slowly  for  ahout  -  in.  flown 
th<'  loop  in  which  it  lies.  This  is  the  movement  of  peristalsis,  and 
it  consists  in  a  dilatation  of  the  '_rnt  beyond  the  bolus,  and  a  con- 
striction on  the  proxini.il  aide  of  it  (Baylisa  and  Starling).  The  w.. 
travel  at  the  rate  of  half  an  inch  to  an  inch  per  minute  after  a  meal, 
and  four  times  as  slowly  during  the  fasting  Btate.  It  is  the  inco- 
ordinated  occurrence  of  constriction  and  relaxation  thai  produ 
colic  and  admits  of  the  possibility  of  intussusception: 

The  other  movements  of  the  small  intestine  are  not  yd 
clearly  understood.  Immediately  after  death,  a  swift  wave  may 
pass  from  the  duodenum  to  the  ileo-caecal  valve  (Houkgeest),  and 
possibly  in  its  course  it  causes  the  multiple  jejunal  intussusceptions 
sometimes  seen  by  the  pathologist.  The  same  movement  may  be 
produced  during  life  by  injecting  a  combination  of  drugs — ergor 
stimulate  the  vagi,  and  calcium  to  inhibit  the  splanchnics  (Meltzer 
and  Auer).  Shorter  rushing  waves  may  sometimes  travel  at  a  much 
higher  rate  than  the  peristaltic  waves,  and  sweep  the  food  without 
pause  through  several  coils.  Meltzer  and  Auer  suggest  that  these 
may  be  an  essential  feature  in  purgation.  Cannon  has  observed 
similar  movements  in  the  small  intestine  after  administering  an  enema 
of  soap  and  water.  Physostigmin  and  ergot  do  not  produce  a  true 
peristalsis,  as,  when  they  are  introduced  into  the  bowel  or  into  the 
blood-stream,  they  cause  violent  local  contractions,  unaccompanied 
by  any  relaxation  of  the  wall  in  front.  These  contractions  are  not 
transmitted  along  the  bowel,  and  therefore  are  ineffectual  in  empty- 
ing it. 

Antiperistalsis  and  vomiting  of  intestinal  contents. 
— Although  antiperistalsis  has  never  been  observed  in  the  small 
intestine  during  the  normal  processes  of  digestion,  the  occur- 
rence of  continued  vomiting  of  intestinal  contents  even  after  the 
stomach  has  been  frequently  washed  out  is  a  common  clinical  experi- 
ence. Many  attempts  have  been  made  to  prove  that  "  faecal  '"'  vomiting 
is  brought  about  merely  by  an  exaggeration  of  a  normal  antiperistaltic 
movement,  but  the  results  are  not  conclusive.  The  first  point  to 
grasp  is  that  the  reflux  of  intestinal  contents  into  the  stomach  occurs 
under  two  different  conditions — one  in  which  there  is  a  mechanical 
obstruction  to  the  onward  passage  of  intestinal  contents,  and  another 
in  which  there  is  paralysis  of  the  intestinal  wall. 

In  the  first  type,  which  is  exemplified  by  strangulated  hernia  and 
malignant  stenosis,  intestinal  movements  are  present  in  an  exaggerated 
degree.     Cannon  experimentally  produced  a  similar  condition  by  T 
a  string  round    the  gut  in  the  upper  part  of  the  jejunum,  and  on 
watching  the  progress  of  a  bismuth  meal  along  the  bowel  he  observed 


428  THE   INTESTINES 

that  the  food  passed  out  of  the  stomach  normally,  and  was  carried 
along  the  duodenum.  When  it  reached  the  obstruction,  powerful  peri- 
staltic waves  followed  each  other  in  quick  succession  and  hurled  the 
contents  against  the  barrier.  As  the  intra-intestinal  pressure  rose,  some 
of  the  fluid  was  squirted  back  through  the  narrowed  lumen  of  the 
contracted  portion  by  peristalsis.  In  this  way,  part  of  the  contents 
might  reach  back  to  the  pylorus,  and  so  enter  the  stomach,  without 
the  occurrence  of  any  antiperistaltic  waves.  In  a  second  experiment, 
in  which  he  stopped  the  progress  of  intestinal  peristalsis  by  reversing 
one  of  the  uppermost  loops  of  the  jejunum,  antiperistaltic  waves 
apparently  occurred  and  carried  the  food  back  to  the  pylorus.  Griitzner 
administered  enemata  of  saline  solution  in  which  were  suspended 
starch  grains,  charcoal,  lycopodium  and  other  substances,  and  he 
recovered  these  particles  from  the  stomach  and  small  intestine.  Such 
a  result  can  only  be  explained  by  the  occurrence  of  antiperistalsis. 

When  the  intestine  is  paralysed,  as  in  general  peritonitis,  it  is 
difficult  to  conceive  that  one  movement — that  of  antiperistalsis — 
should  remain  when  the  other  movements  are  lost.  In  these  cases, 
the  "  faecal  "  vomiting  is  associated  with  distension  of  the  bowel,  the 
contents  of  which  are  decomposing  and  evolving  gases  that  increase 
the  pressure  in  the  canal.  This  pressure  may  become  so  extreme 
that  the  bowel  is  kept  from  bursting  only  by  the  resistance  of  the 
abdominal  wall.  Hence,  at  any  given  point  of  the  bowel,  the  contents 
will  pass  in  the  direction  of  least  resistance.  At  the  lower  end  of  the 
ileum  is  the  ileo-ceecal  sphincter,  which,  we  know,  may  be  tightly 
contracted  although  no  movements  are  occurring  in  the  rest  of  the 
small  intestine.  If,  as  is  probable,  it  is  in  the  same  condition  in  general 
peritonitis,  then  the  accumulating  gases  and  the  copious  secretion 
which  they  as  irritants  induce  must  gradually  force  their  way  upwards 
and  finally  reach  the  stomach,  from  which  the  gases  are  got  rid  of  "by 
frequent  eructations  and  the  liquids  by  vomiting. 

The  results  following  the  administration  of  enemata  in  advanced 
general  peritonitis  favour  the  theory  that  the  ileo-csecal  sphincter  is 
strongly  contracted.  Once  the  colon  has  been  cleared,  the  injected 
fluid  is  returned  unaccompanied  by  any  intestinal  contents,  although 
under  normal  conditions  part  of  the  enema  reaches  the  small  intestine 
and  empties  its  lower  coils. 

In  cases  of  strangulated  hernia,  the  same  explanation  of  "  feecal  " 
vomiting  is  possible,  because  often  it  does  not  begin  till  all  pain  has 
ceased,  and  the  distension  of  the  intestine  is  extreme. 

Movements  of  the  Colon 

Antiperistalsis  is  the  most  frequent  movement  in  the  csecum, 
and  in  the  ascending  and  transverse  colon.     As  soon  as  food  enters 


MOVEMENTS   OF   THE   COLON  429 

the  large  intestine,  a  powerful  contraction  <>f  the  colon  carries  it 
distance  from  the  ileo-csecal  valve;    then  antiperistaltic  waves  begin 

to  pass  rhythmically  bom  the  most  advanced  portion  oi  the  t I 

and  travel  backwards  to  the  caecum.  These  waves  occur  in  "  periods 
during  each  of  which  they  arc  small  to  begin  with,  gradually  reach 
a  maximum,  and  then  die  away.  The  period  Lasts  for  two  to  <'i._r|,t 
minutes  in  the  cat,  and  periods  recur  at  intervals  of  ten  to  thirty 
minutes,  the  bowel  remaining  at  rest  between  them.  In  this  way  tin- 
food  is  thoroughly  mixed  and  presented  for  absorption.  As  food  accu- 
mulates, it  reaches  the  neighbourhood  of  the  splenic,  flexure,  where  tic- 
first  "constriction  ring  "  is  usually  seen.  When  the  intra-intestinal 
pressure  rises,  as  the  food  cannot  force  the  ileo-csecal  sphincter,  some 
of  it 'may  escape  onwards  through  the  ring.  Though  this  explanation 
is  the  one  commonly  accepted,  it  is  possible  that  the  passage  of  the 
most  advanced  contents  into  the  descending  colon  is  brought  about 
by  waves  of  contractions  behind  them.  Otherwise,  the  evacuation 
of  the  half-empty  colon  is  difficult  to  explain.  That  contractions  do 
pass  from  the  cgecurn  along  the  whole  length  of  the  large  intestine  is 
proved  by  Hertz's  observations  on  the  act  of  defecation  in  man. 

In  complete  obstruction  of  the  colon  at  some  distance  from  its 
commencement,  the  antiperistaltic  waves  continue  to  drive  the  food 
backwards,  and  none  of  it  can  move  onwards.  As  the  pressure  rises, 
the  caecum  becomes  dilated,  and  all  the  subjective  symptoms  may  be 
referred  to  the  right  iliac  fossa.  In  cancer  of  the  pelvic  colon,  this 
sometimes  leads  to  confusion  in  diagnosis. 

Constriction  rings. — With  the  increasing  accumulation  of 
food  in  the  ascending  and  transverse  colon,  constrictions  appear  and 
separate  the  contents  into  a  series  of  spherical  masses.  These  increase 
in  number,  and  gradually  assume  a  position  farther  from  the  caecum, 
so  that  they  lie  for  the  most  part  below  the  splenic  flexure.  In  man, 
the  first  is  about  the  middle  of  the  transverse  colon  (Hertz).  With 
the  slow  movement  of  the  constriction  rings,  the  contents  are  gradually 
pushed  onwards  along  the  descending  and  the  pelvic  colon.  This 
movement  corresponds  with  peristalsis  in  the  small  intestine,  and 
each  ring  is  associated  with  an  area  of  dilatation  in  the  gut  below  it. 

Oscillating  contractions  of  the  walls  of  the  sacculi  have  been  observed 
in  the  excised  colon  (Elliott  and  Barclay-Smith).  In  all  probability 
they  assist  in  the  churning  of  the  contents. 

In  defalcation  a  strong  contraction  occurs  to  empty  the  distal 
colon.  According  to  Hertz,  who  has  actually  observed  the  process 
in  man  by  means  of  the  fluorescent  screen,  the  contraction  starts  at 
the  caecum,  and  proceeds  along  the  whole  length  of  the  colon,  driving 
the  contents  farther  down.  It  is  followed  by  similar  waves,  each  of 
which  empties  the  pelvic  colon  of  part  of  its  contents. 


430  THE    INTESTINES 

When  nutrient  enemata  are  administered,  the  contents  lie  at  first 
in  the  descending  and  pelvic  colon,  and  are  then  carried  by  anti- 
peristaltic waves  towards  the  caecum.  Hence  the  function  of  anti- 
peristalsis  is  inherent  in  the  colon  throughout  its  whole  length,  although 
under  normal  conditions  it  is  not  called  into  action  beyond  the  splenic 
flexure.  The  repeated  passing  of  the  waves  mixes  the  contents  of 
the  enema  with  any  digestive  juices  that  may  be  present,  and  promotes 
absorption  of  the  nutriment  at  least  as  far  down  as  the  splenic  flexure  ; 
beyond  this  there  is  little  evidence  of  the  absorption  of  anything 
except  water.  From  Cannon's  experiments  on  animals  it  seems 
likely  that,  if  a  bulky  enema  is  administered,  part  of  it  reaches  the 
lower  ileum. 

Innervation  of  the  Intestine 

The  intestine  can  carry  on  its  functions  to  a  great  extent  indepen- 
dently of  the  central  nervous  system.  In  its  walls  lie  two  nerve- 
plexuses  with  ganglionic  cells — Meissner's  plexus  in  the  submucosa, 
and  Auerbach's  plexus  between  the  circular  and  longitudinal  layers 
of  muscle.  Meissner's  plexus  is  distributed  to  the  mucous  membrane, 
glands  and  villi,  and  is  concerned  with  the  secretory  activities.  Auer- 
bach's plexus  controls  the  movements  of  segmentation  and  peri- 
stalsis in  the  small  intestine,  and  of  antiperistalsis  and  the  tonic 
constrictions  in  the  colon.  Hence  these  movements  can  be  investi- 
gated in  the  excised  gut,  and  they  can  be  induced  or  inhibited  by 
various  mechanical  and  chemical  stimuli.  Thus,  pinching  of  the  gut, 
or  the  introduction  of  butyric  or  some  other  organic  acid,  stimulates 
peristalsis,  and  oxygen  gas  inhibits  it.  The  best  stimulus  is  a  bolus 
introduced  into  the  lumen,  apparently  because  it  produces  a  local 
distension  of  the  bowel. 

At  the  same  time,  the  intestine  is  linked  to,  and  its  functions 
are  under  the  influence  of,  the  central  nervous  system.  It  is  through 
these  connexions  that  the  emotions  so  commonly  produce  derange- 
ments of  the  alimentary  functions.  Cannon  has  shown  in  cats  that 
excitement  and  anger  stop  segmentation  and  peristalsis  in  the  small 
intestine,  and  antiperistalsis  in  the  colon. 

The  small  intestine  is  innervated  by  the  vagi  and  the  splanchnics. 
The  latter  are  also  distributed  to  the  large  intestine,  and  the  fibres 
corresponding  to  those  of  the  vagi  are  supplied  by  sacral  nerve-roots 
through  the  pelvic  visceral  nerves.  The  extrinsic  nerve  supply 
gradually  increases  in  activity,  and  the  local  mechanism  decreases, 
from  the  ileo-csecal  valve  to  the  anus.  Thus,  the  strong  contraction 
of  the  colon  that  produces  defaecation  is  due  to  stimulation  of  the 
fibres  of  the  sacral  nerve  roots. 

The  relationship  between  the  three  systems — local,  sympathetic, 


INNER\   \TI<>\ 

and  cerebro-spina] — is  extremely  complex,  and  is  ^-t  ill  imperfectly 
understood,  l>ut  several  beta  have  been  experimentally  established, 
atatioo  and  peristalsis  in  the  small  intestine,  and  antiperistalsis 
and  peristalsis  in  the  colon,  which  are  the  result  of  a  Local  reflex  action 
effected  through  Auerbach's  plexus,  are  inhibited  by  the  Bplanchnic 
aerves,  irritation  of  which,  as  in  many  acute  abdominal  inflammations, 
arrests  the  movements  and  produces  constipation. 

The  vagi  contain  inhibitory  and  augmentor  iibres  for  the  small 
intestine.  If  they  are  cut  and  their  distal  ends  stimulated,  there  may 
be  temporary  diminution  or  cessation  of  movements — that  is,  inhibi- 
tion; but  if  the  stimulation  is  repeated  five  or  six  times,  inhibition 
is  followed  by  augmentation  of  movements.  After  the  vagi  were  cut, 
Cannon  observed  a  definite  weakness  in  peristaltic  contractions,  with, 
however,  marked  improvement  in  a  few  days  ;  when  both  the  vagi 
and  the  splanchnics  were  cut,  the  peristaltic  contractions  were  prac- 
tically normal  in  appearance,  but  the  transit  of  food  was  slow. 

The  ileo-cctcal  valve  is  also  under  nervous  control.  The  existence 
of  a  definite  sphincter  muscle  at  the  lower  end  of  the  ileum  has  been 
experimentally  proved  (Elliott).  By  impulses  carried  by  the  splanchnic 
nerves,  it  is  kept  in  a  condition  of  moderate  tonic  contraction,  suffi- 
cient to  prevent  regurgitation  of  material  from  the  caecum.  When 
these  nerves  are  cut,  free  mingling  of  the  contents  of  the  small  and 
large  intestine  takes  place.  It  would  also  seem  to  be  relaxed  when 
large  nutrient  enemata  are  given,  a  special  reflex  perhaps  called  into 
play  by  the  emptiness  of  the  ileum.  Stimulation  of  the  splanchnic 
nerves,  which  stops  intestinal  movement,  strongly  contracts  the  ileo- 
cecal valve.  During  the  peristaltic  movements  of  the  lower  ileum, 
the  sphincter  relaxes  in  front  of  each  contraction  and  allows  food 
to  pass  to  the  caecum  ;  when  antiperistalsis  begins  in  the  colon,  it 
closes  and  prevents  regurgitation. 

These  considerations  are  of  practical  importance  ;  for  example, 
the  early  administration  of  fluids  by  the  rectum,  after  an  operation 
for  removal  of  the  appendix,  may  so  increase  the  pressure  within  the 
csecum  as  to  burst  the  sutures  with  which  the  stump  is  invaginated, 
and  this  may  lead  to  the  formation  of  a  faecal  fistula. 

Sensibility  of  the  Intestine  and  Peritoneum 

In  contrast  to  the  parietal  peritoneum,  the  normal  intestine  and 
the  visceral  peritoneum  are  insensitive  to  touch  and  pain.  A  loop 
of  bowel  may  be  pinched,  incised,  or  even  divided  with  the  cautery 
without  the  patient  feeling  it,  and  advantage  is  often  taken  of  this 
fact  in  carrying  out  the  second  stage  of  the  operation  of  colostomy. 

Interference  with  the  blood  supply  of  the  intestine,  irregular  peri- 
stalsis, or  the  presence  of  irritants  in  the  canal  causes  pain,  but  it  is 


432  THE   INTESTINES 

still  uncertain  whether  such  pain  is  referable  to  the  bowel  itself  or  to 
the  parietes. 

Ross  first  described  visceral  pain  as  being  of  two  kinds — splanchnic 
and  somatic,  or,  as  it  is  now  more  frequently  called,  referred  pain. 
Splanchnic  pain  is  located  by  the  brain  in  the  viscus  in  which  it 
originates,  while  somatic  or  referred  pain  is  located  in  a  definite  area 
of  the  body  wall.  As  an  example  of  splanchnic  pain  may  be  cited 
the  pain  which  is  felt  in  the  caecum  when  that  part  of  the  gut  is  dis- 
tended with  flatus.  In  commencing  appendicitis  we  have  an  example 
of  referred  pain,  because,  although  the  lesion  is  in  the  appendix,  pain 
is  felt  in  the  vicinity  of  the  umbilicus. 

The  existence  of  referred  pain  is  now  universally  recognized,  but 
there  is  an  increasing  number  of  clinicians,  of  whom  Mackenzie  was 
the  pioneer,  who  dispute  the  existence  of  splanchnic  pain.  They 
believe  that  the  viscera  are  not  supplied  with  any  nerve  fibres  that 
are  capable,  under  either  normal  or  abnormal  conditions,  of  giving 
rise  to  sensations  of  pain.  The  evidence  on  this  point  is  conflicting. 
but,  if  this  view  is  correct,  it  is  difficult  to  account  for  the  fact  that 
a  patient  can  usually  distinguish  clearly  between  a  superficial  and  a 
deep-seated  pain  in  the  abdomen. 

Referred  pain. — The  accepted  explanation  of  referred  pain  is 
that  the  intestine  is  supplied  by  splanchnic  nerves,  which  are  con- 
nected with  cells  in  the  spinal  cord.  When  a  lesion  of  the  intestine 
exists,  the  splanchnic  fibres  supplying  the  diseased  area  are  irritated 
and  convey  abnormal  impulses  to  their  spinal  cells,  which  are  thus 
stimulated  to  a  condition  of  hypersensitiveness.  These  cells  in  turn 
irritate  neighbouring  sensory  cells  in  the  cornu,  which  send  impulses 
along  their  axis  cylinders  to  their  peripheral  distribution,  and  these 
impulses  are  interpreted  by  the  brain  as  if  they  had  originated  at  the 
periphery  (Pig.  396). 

The  sensitive  structures  to  which  such  stimuli  may  be  referred 
are — (1)  the  skin  and  subcutaneous  tissue,  (2)  the  muscles  of  the 
parietes,  and  (3)  the  parietal  peritoneum  ;  hence,  referred  pain  may 
be  manifested  in  any  of  these  situations. 

The  most  striking  instances  of  referred  pain  are  those  in  which 
the  sensory  nerves  are  distributed  to  a  region  remote  from  the 
diseased  viscus ;  for  example,  in  affections  of  the  bile  passages, 
fibres  of  the  phrenic  nerve  convey  impulses  to  the  4th  and  5th  cervical 
segments.  The  sensory  cells  in  these  segments  supply  the  skin  over 
the  deltoid  ;  hence,  pain  in  disease  of  the  bile  passages  is  often  referred 
to  the  region  of  the  shoulder. 

In  affections  of  the  alimentary  canal,  familiar  examples  of  pain 
referred  to  the  superficial  structures  are  the  pain  of  commencing 
appendicitis  and  of  strangulation  of  small  intestine,  in  each  of  which 


REFLEX    PAIN 


433 


it  is  usually  fell  uear  the  middle  line  in  the  vicinity  of  the  umbilicus. 
In  affections  of  the  colon,  the  pain  is  usually  referred  to  the  hypo- 
gastrium. 

Cutaneous  hyperalgesia  occurs  in  various  abdominal  inflammations, 
and  its  limits  may  be  denned  by  strolsng  the  surface  il  il  is  "super- 
ficial," or  by  pinching  the  skin  if  it  is  '"  deep." 

(iANGLION    Or 
POSTERIOR    NERVE   ROOT 


Fig.  396. — Diagram  of  the  course  of  reflex  pain  (see  text). 

Muscular  hyperalgesia  may  be  present  in  intestinal  disease,  but 
it  is  difficult  to  differentiate  from  cutaneous  hyperalgesia. 

Muscular  contraction  and  rigidity. — Motor  cells  in  the 
cord  may  also  be  irritated  by  abnormal  impulses  conveyed  by  the 
splanchnic  fibres  (Fig.  396),  and  this  irritation  may  manifest  itself 
either  by  causing  "  muscular  rigidity,"  or  by  disturbing  the 
"  abdominal  reflex." 

Muscular  rigidity  is  the  reflex  which  is  best  recognized  and  is  a 


434  THE   INTESTINES 

symptom  of  great  diagnostic  value.  The  rigidity  may  extend  widely 
and  cause  "  boarding  "  of  the  whole  anterior  abdominal  wall,  or  it 
may  be  localized  to  a  small  area.  Unlike  the  muscles  of  the  limbs, 
in  which  if  part  is  stimulated  the  whole  contracts,  the  muscles  of 
the  abdominal  wall  are  capable  of  contracting  in  segments ;  hence,  in 
limited  intestinal  lesions,  a  correspondingly  small  area  of  rigidity  is 
present.  The  best  examples  of  this  are  the  rigid  contraction  of  the 
upper  portion  of  one  or  other  rectus  in  cases  of  gastric  or  duodenal 
ulcer,  and  the  "  boarding  "  of  the  muscles  of  the  right  iliac  fossa  in 
localized  appendicitis.  The  contraction  may  be  so  well  defined  as  to 
simulate  a  definite  tumour.  In  perforative  conditions  of  the  intestine, 
the  rigidity  involves  the  whole  abdominal  wall,  being  apparently  due 
to  reflexes  set  up  by  peritoneal  irritation. 

As  a  rule,  in  localized  inflammatory  conditions,  the  area  of  muscular 
contraction  approximately  overlies  the  inflamed  viscus,  but  occasionally 
it  is  distant  from  it ;  for  example,  in  some  cases  of  pelvic  appendicitis 
and  of  intussusception,  the  anal  sphincter  is  in  a  state  of  spasm. 

Clinically,  this  rigidity  may  be  detected  by  noting  that  the 
respiratory  movements  of  the  abdominal  wall  are  restricted  or  absent 
in  the  contracted  area  ;  and  on  palpation  this  region  is  firm  and 
"  boarded." 

The  reflex  muscular  contraction  cannot  be  voluntarily  inhibited, 
and  the  rigid  segment  is  the  last  to  relax  during  the  induction  of 
ansesthesia.  In  chronic  conditions  in  which  the  rigidity  is  of  long 
standing,  and  in  exceptionally  acute  inflammatory  affections,  the 
contraction  may  not  be  overcome  even  when  the  anaesthetic  is  pushed 
to  the  utmost  limit  of  safety,  the  fixation  of  the  abdominal  wall 
adding  greatly  to  the  difficulties  of  the  operation. 

In  children  who  resist  handling,  it  is  more  reliable  to  test  the 
abdominal  reflex.  Any  part  of  the  muscle  which  is  rigid  does  not 
twitch  when  the  associated  area  of  skin  is  stroked,  as  it  is  already  in 
a  state  of  contraction. 

Yaso-motor  reflexes. — It  is  a  common  clinical  experience 
that  if  the  abdominal  wall  is  incised  over  an  inflammatory  lesion — for 
example,  a  gastric  ulcer — the  vessels  may  bleed  more  freely  than 
normal.  This  is  due  to  a  vaso-motor  reflex  originating  at  the  seat  of 
the  lesion  and  leading  to  dilatation  of  the  blood-vessels. 

Reflexes  of  peripheral  origin. — The  intestine  may  be 
affected  reflexly  by  stimuli  originating  peripherally,  its  motor  and 
secretory  functions  being  disturbed  in  various  directions.  Thus, 
constipation  or  even  complete  obstruction,  due  to  diminution  or  loss 
of  peristalsis,  may  follow  severe  injuries,  not  only  of  the  abdominal 
wall,  but  also  of  the  chest,  or  even  of  the  limbs. 

Reflexes  between  different  parts  of  the  alimentary 


EXCRETORY    FUNCTION  435 

canal. — Many  of  tlw  clinical  symptoms  of  di  i  the  intestine 

are  to  be  explained  by  reflex  influences  exerted  by  one  pari  "f  the 
trad  on  another,  or  even  by  one  viscus  on  another.  For  example, 
vomiting  of  stomach  contents  is  a  symptom  common  to  many  lesions 
of  the  abdomen,  apart  from  those  of  the  stomach.  Again,  hyper- 
chlorhydria  may  be  induced  by  pathological  changes  in  the  vermiform 
appendix,  which  probably  accounts  for  the  condition  spoken  of  as 
'"  appendicular  dyspepsia." 

Handling  of  one  part  of  the  intestine  may  inhibit  the  peristalsis 
in  other  parts,  and  lead  to  more  or  less  complete  stasis  of  intestinal 
contents.  A  striking  example  is  the  complete  inhibit  ion  of  gastric 
and  intestinal  movements  which  immediately  follows  a  perforation 
or  a  bullet -wound  of  the  stomach  or  intestine — a  protective  reflex 
which  tends  to  prevent  the  escape  of  the  bowel  contents  or  their 
spread  throughout  the  peritoneal  cavity. 

Cannon  has  shown  in  the  cat  that  resection  of  a  portion  of  the 
jejunum,  with  end-to-end  suture,  was  followed  by  closure  of  the 
pyloric  sphincter,  which  persisted  for  six  hours — a  period  sufficiently 
long  to  admit  of  a  protective  plastic  exudate  forming  at  the  seat  of 
the  anastomosis.  When  the  resection  was  made  low  down  in  the 
ileum,  the  closure  of  the  pylorus  did  noi.  last  so  long,  but  the  progress 
of  the  contents  along  the  canal  was  retarded,  a  bismuth  meal  taking 
about  seven  hours  to  reach  the  seat  of  the  anastomosis. 

Excretory  Function  of  the  Intestine 

The  faeces  normally  contain  connective-tissue  fibres,  a  -mall  amount 
of  muscle,  traces  of  fat,  fatty  acids  and  soaps,  remnants  of  starch, 
and  inorganic  crystals.  Though  many  changes  may  take  place  in 
the  constituents,  probably  the  only  one  characteristic  of  disease  of  the 
small  intestine  is  an  increase  in  the  starch  granules. 

The  pigment  of  the  faeces  is  urobilin.  In  health  it  is  only  found 
in  the  colon,  but  in  obstructive  conditions  it  may  be  present  even 
in  the  jejunum.  In  the  small  intestine  are  found  the  bile  pigments, 
bilirubin  and  bihverdin,  which  are  transformed  by  the  bacteria  of 
the  colon  to  urobilin.  In  purgation,  however,  the  faeces  may  contain 
bile  pigments. 

With  ordinary  diet,  the  reaction  of  the  stools  is  almost  neutral. 
If  the  putrefaction  of  proteins  is  increased,  as  in  intestinal  tuber- 
culosis and  dysentery,  it  becomes  alkaline  ;  and  increased  fermen- 
tation of  carbohydrates  produces  acid  stools. 

The  consistence  of  the  faeces  varies  with  the  amounts  of  water, 
fat,  mucus,  and  indigestible  residue  that  they  contain.  Scybala 
are  composed  of  food  taken  some  days  previously,  and  are  formed  in 
the  sacculi  of  the  colon. 


436  THE   [NTESTINES 

The  chief  abnormal  constituents  of  the  faeces  are  mucus,  blood, 
and  pus.  Mucus  in  more  than  a  trace  is  present  only  in  pathological 
conditions.  If  coloured  yellow  by  bilirubin,  it  comes  from  the  small 
intestine  ;  if  white,  it  comes  from  the  colon  or  rectum  (Harley  and 
Goodbody).  In  membranous  colitis,  greyish  shreds  or  casts  are  passed 
al  intervals.  These  may  or  may  not  contain  many  epithelial  cells. 
According  to  Leathes,  the  casts  are  composed  of  chitin  derived  from 
carbohydrates.     Fibrin  is  also  sometimes  present  in  the  shreds. 

Blood  in  the  fasces  may  occur  in  streaks  or  clots  visible  to  the  naked 
eye.  In  intestinal  ulceration  the  clots  are  frequently  adherent  to 
mucus.  If  tarry,  or  like  coffee-grounds,  the  blood  comes  from  the 
•small  intestine  or  upper  colon  ;  no  red  corpuscles  are  recognizable 
microscopically,  and  the  blood  pigment  is  transformed  to  hasmatin. 
If  from  the  pelvic  colon,  the  blood  is  not  so  intimately  mixed 
with  the  fasces.  For  traces  of  blood,  the  benzidin  test  is  the  most 
delicate. 

Pus  is  demonstrated  microscopically.  The  cells  are  less  or  more 
disintegrated  according  as  the  disease  is  in  the  pelvic  colon  or  higher 
up.  In  malignant  disease,  pus  and  blood  occur  after  ulceration  of 
the  growth. 

Bacterial  Decomposition 

In  the  contents  of  the  alimentary  canal,  great  masses  of  bacteria 
are  to  be  seen  microscopically,  and  it  is  commonly  found  that  patho- 
genetic organisms,  such  as  the  pneumococcus  and  the  streptococcus, 
show  a  greatly  decreased  virulence.  It  is  often  difficult  to  cultivate 
the  organisms  found  in  the  intestinal  canal,  though  bacteria  which 
have  escaped  into  the  peritoneal  cavity  through  the  injured  intestine 
are  very  readily  grown  on  artificial  media. 

The  bacterial  masses  are  first  met  with  at  the  lower  end  of  the 
ileum,  though  micro-organisms  are  present  in  smaller  numbers  higher 
up.  They  are  abundant  in  the  colon — so  abundant  that  on  an  ordinary 
diet  they  constitute  33  per  cent,  of  the  dried  fasces  (Strassburger). 
According  to  Schiitz,  the  difficulty  of  cultivation  is  due  to  the  influence 
of  a  vibrio  which  rapidly  devitalizes  the  bacteria.  There  is  no  doubt 
that  the  healthy  intestinal  wall  also  plays  an  important  part  in  des- 
troying abnormal  bacteria  and  regulating  bacterial  growth.  In  health 
the  bacterial  flora  is  extremely  constant,  and  abnormal  varieties  are 
soon  destroyed.  The  normal  bacteria  may  be  decreased  by  diet, 
but  experimental  observation  has  shown  that  they  are  little  influenced 
by  the  so-called  intestinal  antiseptics. 

Varieties  of  bacteria. — The  majority  belong  to  the  Bacillus 
coli  group.  In  some  conditions;  these  may  reach  the  blood  stream, 
and  they  appear  to  produce  mental  unrest.  They  are  excreted 
in  large  numbers  by  the  kidneys,  and  their  presence  in  the  bladder 


[NSPECTION     P  \I.I\\TI<>\ 

sometimes  produces  cystitis.  Other  organisms  are  the  Bacillus  lactis 
aerogenes  and  the  Bacillus  jtutrificus  an  anaerobe.  Themosl  importanl 
pathogenetic  organisms  are  those  of  typhoid,  dysentery,  and  chol< 
but  streptococci  and  staphylococci,  the  bacillus  of  anthrax,  and  the 
Bacillus  pyocyameus  may  also  be  found.  Tubercle  bacilli  can  frequently 
be  demonstrated,  even  when  intestinal  tuberculosis  is  no1  presenl  and 
no  bacilli  are  to  be  Eound  in  the  sputum,  bu1  re  pausl  1"-  taken 

to  distinguish  them  from  the  smegma  bacillus  which  abounds  al  the 
anal  orifice. 

METHODS   OF    EXAMINATION 

In  the  examination  of  the  abdomen,  the  usual  clinical  methods 
are  systematically  employed.  The  patient  should  be  Hat  on  the  back, 
with  the  shoulders  slightly  raised  on  a  pillow,  and  the  knees  flexed 
so  that  the  soles  of  the  feet  are  flat  on  the  bed.  He  should  be 
instructed  to  breathe  through  the  open  mouth. 

By  inspection  the  presence  of  localized  or  general  distension 
may  be  recognized,  especially  in  spare  subjects  with  thin  abdominal 
walls.  If  the  distension  is  extreme,  the  skin  appears  smooth,  shining, 
and  stretched,  and  when  it  is  due  to  ascites  the  umbilicus  may  project 
beyond  the  surface. 

The  movements  of  the  abdominal  walls  with  natural  respiration, 
and  while  the  patient  takes  a  series  of  full  breaths,  should  be  noted. 
This  is  better  appreciated  by  bringing  the  eye  to  the  level  of  the 
abdomen  and  looking  across  it  than  by  looking  down  upon  it. 
Abdominal  movements  of  peristalsis  can  sometimes  be  seen  through 
the  parietes  ;  and  in  cases  of  intestinal  obstruction,  various  patterns 
formed  by  the  dilated  coils  of  gut  may  be  recognized.  The  presence 
of  dilated  veins  in  the  abdominal  wall  is  suggestive  of  some  obstruction 
to  the  portal  circulation  or  of  pressure  on  the  vena  cava. 

Palpation. — The  student  should  acquire  the  habit  of  examining 
all  the  external  hernial  orifices  as  the  first  step  in  the  palpation  of 
the  abdomen.  This  having  been  done,  the  abdomen  must  be  examined 
systematically,  the  flat  of  the  hand  (not  the  finger-tips)  being  light ly 
placed  on  the  skin,  and  the  examination  should  be  so  arranged  that 
any  manipulation  likely  to  cause  pain  is  reserved  to  the  last.  After 
observing  the  respiratory  movement  in  each  segment  of  the  abdominal 
wall,  the  muscular  rigidity  is  tested,  any  localized  area  of  "  boarding  " 
being  specially  noted. 

The  condition  of  the  wall  having  been  thus  determined,  the  hand 
is  again  passed  over  the  abdomen  to  investigate  tin-  contents,  each 
individual  viscus  and  segment  of  the  bowel  being  in  turn  felt  for. 
At  first  only  a  moderate  degree  of  pressure  should  be  exercised  :  later, 
if  this  is  tolerated,  deeper  pressure  can  be  made.     In  this  way,  local 


438  THE   INTESTINES 

or  general  distension  of  the  bowel,  enlargement  of  a  viscus,  such  as 
the  gall-bladder,  the  spleen,  or  the  pancreas,  or  the  presence  of  a 
tumour  may  be  recognized.  If  a  localized  swelling  is  detected,  its 
size,  shape,  consistence,  mobility,  and  degree  of  tenderness  should 
be  determined,  and  an  attempt  made  to  ascertain  whether  it  moves 
with  respiration.  In  estimating  the  degree  of  tenderness,  more  reliable 
information  is  obtained  by  watching  the  facial  expression  of  the  patient 
than  from  his  verbal  statements.  A  swelling  in  the  line  of  the  bowel 
should  be  firmly  pressed  upon  with  the  finger-tips  to  see  if  it  is  indented 
or  "  pitted  "  by  the  pressure — an  indication  that  it  is  a  fsecal  mass. 

In  testing  for  fluctuation  when  ascites  is  suspected,  an  assistant 
should  press  with  the  ulnar  side  of  his  hand  in  the  line  of  the  linea 
alba  to  cut  off  vibrations  of  the  parietes. 

The  lateral  aspects  of  the  abdomen  should  be  examined  with  one 
hand  placed  behind  in  the  loin  and  the  other  over  the  abdomen  in 
front. 

It  is  sometimes  useful  to  examine  the  patient  lying  on  the  side 
or  in  the  knee-elbow  position. 

Percussion. — The  note  elicited  by  percussion  over  the  hollow 
viscera  is  tympanitic,  the  pitch  varying  with  the  quantity  of  gas 
present  and  its  tension.  The  character  of  the  note  is  influenced  by 
the  presence  of  fluid  or  faeces  in  the  viscus.  Under  pathological  con- 
ditions, it  is  not  always  easy  to  identify  one  part  of  the  intestinal 
tract  from  another  by  percussion  alone,  but  the  employment  of  com- 
bined percussion  and  auscultation  is  sometimes  helpful.  The  stetho- 
scope is  placed  over  the  viscus  under  examination,  and  by  percussing 
close  to  it  the  characteristic  note  of  that  viscus  is  recognized.  Percus- 
sion is  then  made  well  beyond  the  hmits  of  the  viscus,  and  a  different 
note  is  elicited.  If  the  percussion  is  now  continued  towards  the 
stethoscope,  the  original  note  is  again  recognized  when  the  limit  of 
the  viscus  is  reached.  Variations  in  pitch  of  the  note  over  different 
viscera  may  be  detected  by  scratching  the  surface  instead  of  percussing. 
"When  a  moderate  amount  of  free  fluid  is  present  in  the  peritoneal 
cavitv,  as  in  ascites,  the  most  dependent  parts  yield  a  dull  note  on 
percussion  while  the  higher  parts  are  tympanitic,  as  the  intestine  is 
floated  up  by  the  fluid.  By  changing  the  attitude  of  the  patient, 
the  dull  and  tympanitic  areas  are  found  to  alter.  When  the  ascites 
is  extreme,  this  test  is  less  convincing. 

If  the  intestine  is  paralysed  and  full  of  fluid,  a  dull  note  may  be 
elicited  in  the  flanks,  and,  on  succussion,  splashing  may  be  detected. 
In  every  case  the  suprapubic  region  should  be  percussed  to  define 
the  upper  limit  of  the  bladder,  and  if  it  is  found  to  be  distended  it 
should  be  emptied,  by  the  catheter  if  necessary,  before  the  examina- 
tion is  completed. 


EXAMINATION 

Auscultation  doea  noi   yield  much  information   in  abdominal 
conditions.    In  obstruction  of  the  bowel,  bubbling  or  gurgling  sound 
— "stenosis  noises" — may  be  beard;    in  relaxed  and  dilated  bowel, 
Bplashing  sounds  may  be  elicited  on  succussion. 

A  digital  examination  of  the  rectum  and  vagina 
should  be  made  in  every  ruse  in  which  symptoms  are  referable  to 
the  intestine.  Distension  of  the  lower  bowel  with  air  or  water  is  of 
doubtful  value  as  a  diagnostic  measure,  and  is  not  devoid  of  risk. 

The  Rontgen  rays  are  of  value  in  determining  the  presence 
and  position  of  foreign  bodies  in  the  intestine.  After  administration 
of  a  bismuth  meal — say,  bread  and  milk  with  which  2  oz.  of  subcrbonate 
of  bismuth  have  been  thoroughly  mixed — the  passage  of  the  food  along 
the  intestinal  canal  can  be  traced  by  periodic  observations  made 
through  the  fluorescent,  screen,  or  by  taking  a  series  of  X-ray  photo- 
graphs. For  the  investigation  of  conditions  in  the  colon,  an  emulsion 
of  bismuth  in  olive  oil  may  be  introduced  directly  into  the  bowel. 
The  results  obtained  by  these  measures,  when  employed  for  the 
localization  of  an  obstruction  in  the  bowel,  require  to  be  carefully 
interpreted,  and  they  should  not  be  allowed  to  outweigh  those  obtained 
by  ordinary  clinical  methods.1 

The  sigmoidoscope  is  of  great  value  in  investigating  the 
condition  of  the  lower  bowel  as  far  as  the  pelvic  colon.  The  long 
tubular  speculum,  which  carries  a  metal  filament  lamp  to  illuminate 
the  bowel  and  is  provided  with  a  bellows  by  which  air  can  be  pumped 
in  to  distend  the  gut,  is  passed  with  the  patient  in  the  knee-elbow 
position  or  in  the  'left  Sims'  position.  In  the  introduction  of  the 
instrument,  care  must  be  taken  by  altering  its  axis  to  round  the 
curves  without  pressing  on  the  wall  of  the  gut. 

MALFORMATIONS 

Development.— In  the  early  embryo,  the  primitive  alimentary 
canal  is  represented  by  an  incomplete  tubular  cavity  lying  beneath 
the  notochord,  and  continuous  with  the  yolk  sac.  As  the  embryo 
becomes  folded  in  its  growth,  this  tube  is  differentiated  into  the  fore-gut, 
from  which  are  developed  the  phar)*nx,  oesophagus,  stomach,  and 
duodenum  as  far  down  as  the  opening  of  the  common  bile-duct,  as 
well  as  the  organs  formed  as  outgrowths  from  these  ;  the  hind-gut, 
from  which  the  rectum  and  a  variable  portion  of  the  descending  colon 
are  developed  ;  and  the  mid-gut,  which  gives  origin  to  the  remainder 
of  the  intestinal  canal.  At  first,  the  mid-gut  is  continuous  with 
the  cavity  of  the  yolk  sac,  but  in  time  the  communication  becomes 
narrowed  and  constitutes  the  vitelline  duct,  a  remnant  of  which  some- 
times persists  in  the  form  of  a  Meckel's  diverticulum. 
1  See  also  Vol.  I.,  p.  622. 


44°  THE   INTESTINES 

As  development  proceeds,  the  primitive  canal  becomes  greatly 
elongated,  and  the  mid-gut  is  differentiated  into  the  large  and  small 
intestines,  the  junction  being  indicated  by  an  outgrowth  which  even- 
tually forms  the  caecum. 

Concurrently  with  the  elongation  of  the  tube  and  the  development 
of  its  mesentery,  which  carries  the  superior  mesenteric  artery,  there 
is  a  rotation  of  the  mid-gut,  which  brings  the  large  intestine  across 
the  duodenum,  and  the  caecum  to  the  right  side  just  below  the  liver. 
From  this  position  it  gradually  descends  to  the  right  iliac  fossa.  The 
small  intestine  goes  on  increasing  in  length,  and  is  thrown  into  the 
complicated  series  of  coils  characteristic  of  the  adult  bowel. 

CONGENITAL   CONSTRICTIONS   AND    OCCLUSIONS 

The  small  intestine  may  be  narrowed  or  occluded  in  a  variety  of 
ways.  At  the  junction  of  the  fore-  and  mid-guts,  for  example,  the 
canal  may  be  interrupted  by  a  septum,  or  by  an  annular  constriction, 
probably  due  to  faulty  development  of  the  embryonic  buds  in  which 
the  liver  and  pancreas  arise  (Bland-Sutton).  A  complete  segment 
of  the  bowel — jejunum  or  terminal  portion  of  ileum — may  be  absent, 
together  with  a  U-shaped  portion  of  the  mesentery  ;  sometimes  there 
are  multiple  defects.  Among  the  other  congenital  lesions  of  the  jejunum 
and  ileum  that  have  been  met  with  are  septa,  localized  strictures,  and 
adhesions  from  foetal  peritonitis.  The  segment  above  the  obstruction 
is  dilated  and  elongated,  that  below  is  contracted. 

Congenital  defects  in  the  colon  are  usually  met  with  at  the  various 

flexures,   where  portions  may  be  absent  or  septa  may  occlude  the 

lumen. 

DIVERTICULA 

Congenital  diverticula  are  occasionally  met  with  in  the  region  of 
the  duodenum,  and  in  a  certain  proportion  of  cases  masses  of  pan- 
creatic tissue  are  found  at  the  fundus  of  the  pouch. 

In  the  small  intestine  acquired  diverticula  are  not  common.  They 
are  usually  multiple,  varying  in  size  from  a  pea  to  a  hen's  egg,  and 
are  found  on  the  mesenteric  edge  of  the  bowel,  particularly  towards 
the  lower  end  of  the  ileum.  They  consist  of  pouches  of  mucous 
membrane  protruded  through  the  muscular  coat  along  the  line  of  the 
small  vessels  that  enter  and  leave  the  submucous  tissue,  and  they 
push  themselves  between  the  layers  of  the  mesentery.  These  diver- 
ticula are  probably  due  to  increased  intra-intestinal  pressure  and 
irregular  tonic  contraction  of  the  bowel.  A  case  has  been  recorded 
by  Alexis  Thomson  in  winch  a  localized  focus  of  tuberculosis  weakened 
the  wall  and  admitted  of  the  formation  of  a  diverticulum ;  and 
another  in  which  an  accessory  pancreas  was  present  at  the  apex  of 
the  diverticulum.     (Plate  92.) 


/ 


Complete  longitudinal  section  of  diverticulum  with  accessory 
pancreas,      x  5. 

a,   Extreme  apex  of   diverticulum  ;    /',  fat  :    < .   larger  portion  of  accessory  pancreas  emledded    in 
extraperitoneal    fat  ;    ti,    smaller    portion    of    accessory    pancreas  ;    e,  blood-vessels ;  /,  longi- 
tudinal muscle  fibres  of  coat  of   bowel  ;   g;  circular  muscle  fibres  ;    //,  mucosa  with  villi  and 
solitary  glands  ;  /,  lumen  of  diverticulum. 
(/>,!■  courtesy  of  Professor  Alexis   Thomson.     Edin.    Med.  fount.,  vol.   xxiii..   New  Series.) 

Plate  92. 


MYI-.K  I "ICl   I    \    «  )l     CO!  ON 


IM 


ilai  pressure  diverticula  are  by  no  means  uncommon  in  the 
colon,  particularly  in  the  pelvic  colon  and  lower  pari  of  the  d< 
ing  colon.    They  are  not  confined  to  the  line  of  the  mesenteric  attach- 
ment,  but   may  form  anywhere  between  the  longitudinal  muscular 
bands,  and  they  Bometimes  pass  into  an  appendix  epiploi 

tally   multiple,   they   vary   in   size   from  a  tin;.-   saccule   just 
admitting  a  probe,  to  an  elongated  pouch  resembling  at  firsl 
.    Meckel's   diverticulum.     Muscular   tissue    has   been   found   in  the 


Fig.  397. — Meckel's  diverticulum  attached  to  abdominal  wall. 

wall  of  the  pouch  in  some  eases.  They  often  contain  concretions 
composed  of  inspissated  faecal  matter,  cholesterin,  or  calcium  carbonate. 
The  presence  of  such  foreign  bodies  causes  irritation  of  the  mucous 
membrane — diverticulitis  (p.  510) — and  this  may  result  in  abscess 
formation  and  perforation,  or  may  set  up  chronic  pericolitis  with 
the  formation  of  an  inflammatory  cicatricial  mass  which  may  simulate 
malignant  disease  (p.  515).  In  some  cases,  the  formation  of  an  abscess 
has  resulted  in  the  production  of  fistulous  communications  with  the 
bladder. 

Meckel's  Diverticulum 
Meckel's  diverticulum  is  a   congenital  abnormality  of  the   small 
intestine  due  to  persistence  of  the  intra-abdominal  part  of  the  vitelline 
duct,  which,  under  normal  conditions,  should  be  obliterated  during 


442 


the  intestines 


the  sixtli  or  seventh  week  of  foetal  life.  It  usually  springs  from 
the  convex  free  border  of  the  ileum  somewhere  within  2  ft.  of  its 
termination  at  the  ileo-csecal  valve. 

Varieties. — As  the  process  of  obliteration  may  be  arrested  at 
any  stage,  this  deformity  manifests  itself  in  many  varieties.  It  has 
been  estimated  that  a  Meckel's  diverticulum  is  present  in  2  per  cent, 
of  human  subjects,  but  in  the  vast  majority  of  cases  it  is  simply  repre- 
sented by  a  small  thimble-like  pouch  which  causes  no  trouble  and 
gives  rise  to  no  inconvenience. 


Prolapsed  mucous 

. 

Opening  of  _ 

0    « 

diverticulum 

^\ W 

_£A.3. 

Umbilicus 


Fig.  39S. — Patent  Meckel's  diverticulum  in  a  child  aet.   i  year. 
(Author'1  s  case.) 

It  may  persist  as  a  patent  canal,  opening  at  the  umbilicus  at  one 
end  and  into  the  ileum  at  the  other,  constituting  one  form  of  umbilical 
fistula.  The  mucous  membrane  is  sometimes  prolapsed,  forming  a 
reddish,  conical  projection  at  the  umbilicus  (Fig.  398),  from  which 
exudes  a  quantity  of  clear  mucus,  occasionally  mixed  with  faacal  matter. 
Sometimes  it  forms  a  sinus,  opeuing  at  the  umbilicus  but  ending 
blindly  a  short  distance  inside  the  abdominal  cavity.  The  most 
common  form  is  a  short  tubular  or  saccular  pouch  of  variable  length 
(Fig.  399),  with  a  well-formed  mesentery,  which  passes  in  front  of  the 
ileum  and  has  an  artery  running  in  its  free  border  :  or  the  mesentery 
may  be  merely  represented  by  a  fibrous  cord  passing  from  the  mesen- 
tery of  the  ileum  to  the  tip  of  the  diverticulum.  In  other  cases  it  is 
narrowed  down  to  a  long,  vermiform,  or  even  filiform,  process,  which 
sometimes  ends  in  a  bulbous  enlargement  (Fig.  397). 


MECKEL'S   DIVERTICULUM 


1 1 


On  the  other  band,  it  may  become  pear-shaped,  or  even  spherical, 
and  undergo  considerable  hypertrophic  thickening,  and,  it'  Ll  becomes 
occluded  a1   each  end,  it    Eorms  a  cystic  tumour  filled  with  mucus 

(Fig.   l""1 

The  structure  of  the  pervious  portion  of  the  diverticulum  is  similar 
to  th.n  of  the  lower  ileum.  A  scries  of  cases  has  recently  been  recorded 
in  which  masses  of 
pancreatic  t  issue 
were  Eound  embed- 
ded in  the  wall  of 
the  diverticulum,  a 
condition  which  is 
probably  to  be  ex- 
plained by  the  fad 
that  until  the  third 
week  of  development 
the  mouth  of  the 
yolk  sac  extends  up 
to  the  second  part 
of  the  duodenum, 
where  the  pancreas 
has  its  origin. 

Tin'  vascular  cord 
of  the  diverticulum 
may  be  represented 
by  an  impervious 
fibrous  band  —  the 
terminal  ligament — 
which  is  attached  to 
the  anterior  abdo- 
minal wall  at,  or 
some  distance  below, 
the  umbilicus  (Fig. 
397).  The  end  of  a 
free  diverticulum  or  the  terminal  ligament  may  form  new  attach- 
ments to  the  mesentery  of  the  ileum,  to  an  adjacent  coil  of  bowel, 
or  to  some  other  viscus,  and  form  an  arcade  or  ring  through  which 
a  loop  of  bowel  may  pass  and  become  strangulated  (Fig.  401). 

Complications.— 1.  Inflammation  of  a  Meckel's  diverticulum 
—diverticulitis— is  attended  with  symptoms  closely  resembling  those 
of  appendicitis,  a  condition  for  which  it  is  usually  mistaken  before 
the  abdomen  is  opened. 

2.  In  a  considerable  proportion  of  cases,  the  ileum  is  narrowed 
at,  or  more  frequently  just  above,  the  level  at  which  the  diverticulum 


Fig.  399. 


Tubular  form  of  Meckel's 
diverticulum. 

(Anatomical  Museum,   University  of  Edinburgh.) 


444 


THE   INTESTINES 


arises.  This  narrowing  may  be  clue  to  defective  development  of  the 
segment  implicated,  or  to  cicatricial  contraction  following  ulcera- 
tion of  the  gut  at  the 
opening  of  the  pouch, 
or  it  may  result  from 
traction  exerted  on 
the  gut  by  the  di- 
verticulum or  its  me- 
sentery. 

3.  Intussuscep- 
tion is  sometimes 
originated  by  a  Meck- 
el's diverticulum  be- 
coming inverted  and 
projecting  into  the 
lumen  of  the  ileum, 
where  it  forms  the 
apex  of  the  intussus- 
ception. 

4.  Volvulus  has 
been  produced  by 
the  weight  of  a  dis- 
tended Meckel's  di- 
verticulum rotating 
the  bowel  on  its  me- 
senteric axis  ;  or  the 
diverticulum  may  it- 
self be  twisted  on  its 
long  axis.  The  com- 
bination of  volvulus 
and  kinking  is  not 
uncommon. 

5.  By  far  the  most 
common  complication 
is  strangulation  of 
the  bowel  by  the 
diverticulum  acting  as 
a  band.  When  the 
diverticulum  remains 
attached  to  the  um- 
bilicus and  stretches 
across    the    abdomen 

(Fig.  397),  a  coil  of  bowel  may  be  kinked  over   it,  hanging   like   a 
towel  over  a  rope.     More  frequently  the  free  end,  by  forming  new 


S    i 


•3  ~~. 


V 


MECKEL'S   DIVERTICULUM 

attachments,  has  made  a  ring  through  which  a  Loop  of  bowel  Blips 
(Eig.  l"h.  When  the  apex  remains  free,  and  especially  if  it  is 
long  and  ends  in  a  rounded  knob,  a  loop  of  bowel  may  be  Bnarcd 
or  noosed  by  it,  and  the  knots  thus  formed  may  be  mosl  compli 
The  condition  is  most  usually  me1  with  in  young  adult  m 
with  no  history  of  previous  injury  or  peritonitis  such  as  would  give 
rise  to  the  formation  of  a  fibrous  band.  The  obstructive  symptoms 
are  nol   always   acute  a1   the  onset,  as    the    diverticulum    does    not 


Terminal  ligament  adli 
t"  mesentery 

Fig.  401. — Meckel's   diverticulum   causing  obstruction  of 
the  bowel  by  snaring  a  loop  of  small  intestine. 

(Anatomical  Museum,   University  of  Edittburgk.) 

grasp  the  bowel  tightly,  but  as  it  becomes  oedematous  and  the  con- 
stricted bowel  distends  they  become  more  acute.  Gangrene  of  the 
diverticulum  soon  supervenes,  or  perforation  occurs,  and  peritonitis 
sets  in  early.  There  are  no  symptoms  by  which  strangulation  of 
the  bowel  by  a  Meckel's  diverticulum  can  be  distinguished  from 
obstruction  due  to  other  forms  of  band. 

6.  A  Meckel's  diverticulum,  either  alone  or  together  with  the 
portion  of  ileum  from  which  it  springs,  may  form  one  of  the  contents 
of  an  inguinal  hernia,  less  frequently  of  a   femoral  hernia   (Littre's 


446  THE   INTESTINES 

hernia).  Strangulation  is  a  frequent  complication  of  such  hernias,  but 
when  the  diverticulum  alone  is  in  the  sac  the  symptoms  are  less  acute 
than  in  strangulation  of  the  ileum.  Taxis  is  particularly  dangerous, 
as  the  diverticulum  is  liable  to  rupture  at  its  base  ;  and,  owing  to 
the  poor  blood  supply,  gangrene  and  perforation  of  the  diverticulum 
rapidly  occur. 

The  clinical  features  of  these  various  complications  differ  but 
slightly  from  those  of  the  same  conditions  arising  from  other  causes, 
and  the  treatment  is  carried  out  on  the  same  lines. 

HIRSCHSPRUNG'S  DISEASE  or   "IDIOPATHIC  DILATATION 

OF   COLON" 

The  condition  known  as  Hirschsprung's  disease  is  usually  met 
with  in  young  children,  and  is  characterized  clinically  by  obstinate 
constipation  dating  from  birth,  and  extreme  distension  and  enlarge- 
ment of  the  abdomen.  The  colon,  in  whole  or  in  part,  is  greatly 
dilated  and  hypertrophied,  without  there  being  any  organic  obstruction 
distal  to  the  dilated  portion. 

Morbid  anatomy. — From  a  study  of  the  recorded  cases,  it 
would  appear  that  the  anal  canal  and  rectum  are  usually  perfectly 
normal,  the  dilatation  beginning  in  the  lower  part  of  the  pelvic  colon 
and  affecting  the  whole  of  this  segment  of  the  bowel,  so  that  it  forms 
an  enormous  loop,  sometimes  as  thick  as  a  man's  thigh,  and  extending 
up  to  the  right  costal  margin.  In  most  cases  the  dilatation  affects 
the  pelvic  colon  alone,  but  in  some  it  extends  to  the  iliac  and  descend- 
ing portions  of  the  colon.  Less  frequently  the  transverse  colon  is  also 
enlarged,  and  still  less  frequently  the  ascending  colon  and  caecum. 
The  small  intestine  invariably  appears  normal  in  size  and  structure. 

The  wall  of  the  affected  portion  is  greatly  thickened,  chiefly 
from  enormous  hypertrophy  of  the  circular  muscular  coat.  In  cases 
of  long  standing  there  is  considerable  fibrous  hyperplasia  of  the  bowel 
wall — an  evidence  of  "  chronic  interstitial  colitis." 

When  scybalous  masses  are  retained  in  the  dilated  bowel,  numerous 
irregular  ulcers  of  the  mucosa,  extending  down  to  the  circular  muscular 
coat,  are  present.  Perforation  of  such  an  ulcer  has  proved  fatal. 
The  dilated  bowel  contains  great  quantities  of  gas,  a  variable  but 
usually  small  amount  of  semi-solid  fsecal  matter,  and,  occasionally, 
masses  of  hardened  faeces. 

On  microscopical  examination  the  mucosa  shows  some  degree  of 
leucocyte  infiltration  ;  the  muscularis  mucosae  is  slightly  hypertro- 
phied and  shows  interstitial  fibrous  changes  ;  and  the  submucous  coat 
is  more  fibrous  than  normally,  its  blood-vessels  are  more  numerous, 
and  lymphocyte-like  cells  are  collected  round  them  in  great  numbers. 
The  circular  muscular  coat  shows  an  extreme  degree  of  true  muscular 


HIRSCHSPRUNG'S    DISEASE 


-1-17 


hypertrophy,  being  frequently  four  01  five  times  its  normal  thickness. 
In  old-standing  cases  the  muscle  may  be  replaced    to  some  extent 


Fig.  402. — Case  of  Hirschsprung's  disease. 

(From  a  photograph  in  the  author's  colli 


44§  THE   INTESTINES 

by  dense  connective-tissue  fibres.  The  longitudinal  muscular  coat  is 
also  hypertrophied,  but  to  a  less  extent  than  the  circular  coat.  The 
serous  coat  shows  some  degree  of  fibrous  thickening  (D.  P.  D.  Wilkie). 

Etiology. — Great  difference  of  opinion  exists  as  to  the  deter- 
mining cause  of  these  changes  in  the  colon,  and  it  would  appear  that 
no  one  of  the  causative  factors  to  which  the  condition  has  been  assigned 
is  sufficient  to  account  for  all  the  manifestations  of  the  disease.  It 
seems  probable  that  a  number  of  causes,  some  anatomical,  others 
physiological,  are  at  work.  Such  a  combination  as  that  suggested 
by  Wilkie  offers  a  rational  and  intelligible  explanation  of  the  sequence 
of  events. 

In  the  newly-born  infant,  the  pelvic  colon  and  its  mesentery  are 
relatively  long  and  lax,  and  the  mesocolon  has  an  extensive  attach- 
ment to  the  posterior  abdominal  wall,  so  that  this  segment  of  the 
bowel  enjoys  a  wide  range  of  mobility.  At  birth,  the  lower  part  of 
the  large  intestine,  particularly  the  pelvic  colon,  is  distended  with 
meconium.  If,  from  any  cause,  the  muscular  tone  of  the  infant's 
bowel  is  below  normal,  it  is  easy  to  understand  how  this  distension 
may  proceed  to  such  an  extent  as  to  render  the  bowel  incapable  of 
contracting  on  its  contents  and  expelling  them.  The  retained  meconium 
soon  undergoes  bacterial  decomposition,  and  fermentative  gases  are 
formed  and  add  to  the  distension.  From  the  combined  weight  of 
the  contents  and  the  gaseous  distension,  the  mobile  loop  of  the  bowel 
may  readily  become  bent  or  kinked,  even  to  such  an  extent  as  to  fold 
or  press  upon  the  upper  end  of  the  rectum  and  so  occlude  it,  as  by  a 
valve.  When  the  distension  increases  sufficiently,  the  pelvic  colon 
rises  into  the  abdomen  and  temporarily  opens  the  valve,  and  some 
of  the  contents  may  escape. 

In  its  efforts,  only  partly  successful,  to  overcome  the  obstruction, 
the  bowel  wall  becomes  hypertrophied  and  thickened. 

"  The  relation  which  the  hypertrophy  bears  to  the  dilatation 
determines  the  fate  of  the  case.  When  the  hypertrophy  fails  to  keep 
pace  with  the  dilatation,  we  get  early  obstructive  symptoms  with 
distension,  and  frequently  death  from  toxaemia  in  infancy  or  early 
childhood.  When  the  hypertrophy  is  sufficient  to  compensate  for 
the  dilatation,  the  child  may  reach  adult  life,  suffering  only  from  a 
slightly  swollen  abdomen  and  a  certain  degree  of  constipation.  Adult 
life  being  reached,  compensation  does  not  usually  fail  till  the  de- 
generative changes  of  old  age  begin  to  set  in  ;  then,  from  fibrous 
changes  occurring  in  the  hypertrophied  wall,  compensation  fails. 
the  bowel  dilates  further,  and  leads  to  the  well-known  symptoms  " 
(Wilkie). 

Clinical  features. — The  condition  is  much  commoner  in  boys 
than  in  girls,  and  is  usually  met  with  during  the  first  year  of  life, 


HIRSCHSPRUNG'S   DISEASE  \\> 

although  its  recognition  may  be  delayed  till  later  childhood,  or  even 
till  adult  life. 

When  the  compensatory  hypertrophy  tails  to  overcome  the  dis- 
tension, the  symptoms  appear  in  early  infancy  and  tend  to  become 
acute.  The  mosl  constant  and  characteristic  symptom  is  obstinate 
constipation  dating  Erom  birth,  the  bowels  failing  to  move  for  Beveral 
days  at  a  time  in  spite  of  the  free  use  of  purgatives.  Electa]  injections 
usually  afford  temporary  relief,  but  it  is  only  by  their  constant  repeti- 
tion that  the  action  of  the  bowels  can  be  secured.  The  motion 
as  a  rule,  small,  soft,  and  very  offensive,  and  some  flatus  may  be  passed. 
Occasionally  small,  hard  scybalous  masses  are  removed  by  an  enema. 

Flatulent  distension  is  soon  manifest,  the  abdomen  becoming  pro- 
minent, particularly  in  its  upper  part,  and  the  lower  ribs  being  raised 
and  pushed  outwards,  so  that  the  abdomen  appears  to  be  lengthened 
in  contrast  with  the  shortened  thorax.  The  distended  coils  may 
form  a  pattern  when  a  peristaltic  wave  passes  along  them,  and  loud 
borborygmi  may  be  heard. 

Sometimes  the  rectum  is  ballooned,  sometimes  it  is  contracted 
as  if  in  a  state  of  muscular  spasm,  but  there  is  never  any  organic 
obstruction.  Vomiting  is  not  a  constant  symptom,  and  it  almost 
never  becomes  faecal. 

The  pressure  of  the  distended  bowel  upon  the  diaphragm  inter- 
feres with  respiration  and  with  the  heart's  action.  The  patient  becomes 
drowsy  and  listless,  emaciates  rapidly,  and,  unless  relieved,  dies  of 
toxaemia  or  from  the  effects  of  perforation. 

When  the  hypertrophy  keeps  pace  with  the  dilatation,  the  symptoms 
are  less  urgent.  Constipation  may  be  as  obstinate,  but  the  abdominal 
distension  is  less  marked,  great  quantities  of  flatus  are  passed,  and 
there  is  seldom  vomiting.  The  general  nutrition  is  defective,  and  as 
the  patient  is  constantly  absorbing  toxins  from  the  colon,  he  becomes 
thin,  sallow,  and  depressed.  Sooner  or  later,  however,  compensation 
fails,  and  more  acute  symptoms  of  obstruction  supervene,  death 
resulting  from  toxaemia  or  from  peritonitis  following  perforation. 

Treatment. — In  early  cases  in  which  there  is  reason  to  believe 
that  the  compensatory  hypertrophy  is  efficient,  medical  measures 
designed  to  improve  the  muscular  tone  of  the  colon  and  to  prevent 
fermentation  of  the  contents  are  indicated.  Such  drugs  as  strych- 
nine, belladonna,  pituitary  extract,  and  intestinal  antiseptics  may 
be  administered.  The  frequent  and  systematic  use  of  large  high 
enemata  is  of  great  value,  and  it  may  be  supplemented  by  abdominal 
massage  and  the  use  of  electrical  treatment. 

When  compensation  is  defective,  or  when  medical  measures  have 
failed,  recourse  must  be  had  to  operative  treatment,  and  this  should 
be  undertaken  before  the  patient  is  suffering  from  toxaemia. 
■Id 


45°  THE    INTESTINES 

The  appropriate  operation  can,  as  a  rule,  only  be  decided  upon 
after  the  abdomen  has  been  opened,  and  the  actual  state  of  affairs 
recognized. 

"\\  hen  practicable,  resection  of  the  affected  segment,  with  anasto- 
mosis of  the  bowel  above  and  below,  is  the  ideal  operation,  but  as  tho 
dilatation  often  extends  right  down  to  the  commencement  of  the 
rectum  it  is  not  always  feasible.  Entero-anastomosis,  or  short- 
circuiting  of  the  bowel — the  lower  end  of  the  ileum  being  anastomosed 
laterally  with  the  pelvic  colon — has  in  a  few  cases  given  relief. 

Colostomy  affords  great  relief  in  acute  cases,  and  may  tide  the 
patient  over  till  a  more  extensive  operation  can  be  undertaken.  In 
many  cases  the  relief  afforded  by  a  small  colostomy  opening  acting 
as  a  safety-valve  for  the  escape  of  flatus  has  added  greatly  to  the 
comfort  and  safety  of  the  patient. 

Colopexy  and  eoloplication  have  not  yielded  encouraging  results. 

ENTEKOFFOSIS 

(Glenabd's   Disease — Splanchnoptosis — Visceroptosis) 

It  is  only  necessary  here  to  refer  to  the  surgical  aspects  of  this 
affection.  A  fuller  description  of  its  various  manifestations  will  be 
found  in  works  on  Medicine. 

Glenard,  in  1885,  first  systematically  described  the  condition, 
which  consists  in  a  sinking  of  the  stomach,  transverse  colon,  and  right 
kidney  to  a  lower  level  in  the  abdominal  cavity  than  they  normally 
occupy.     Other  viscera  sometimes  share  in  the  prolapse. 

Etiology. — The  displacement  is  probably  due  to  a  combination 
of  causes,  by  which  the  processes  of  peritoneum  that  naturally  sus- 
pend the  viscera  become  relaxed  or  stretched.  Among  the  factors 
that  bring  this  about  may  be  mentioned  weakness  and  atony  of  the 
muscles  of  the  anterior  abdominal  wall  resulting  from  repeated 
pregnancies,  or  following  an  exhausting  illness ;  compression  of  the 
thorax  and  abdomen  by  tight  corsets ;  excessive  dragging  on  the 
suspensory  ligaments  by  the  weight  of  a  dilated  stomach,  an  over- 
distended  colon,  or  a  tumour  ;  or  the  weight  of  an  enlarged  liver 
or  spleen,  pushing  the  organs  down  into  the  lower  parts  of  the 
abdomen. 

Clinical  features. — Enteroptosis  may  exist  to  a  marked 
degree  without  giving  rise  to  any  discomfort,  and  the  severity  of 
the  symptoms  is  not  proportionate  to  the  degree  of  displacement  of 
the  viscera.  As  a  rule,  however,  the  patient  complains  of  a  constant 
sense  of  weight,  and  a  dragging  pain  in  the  abdomen  and  loins,  aggra- 
vated by  exertion  and  relieved  by  lying  down,  and  suffers  from  so- 
called  "  nervous  dyspepsia,"  with  pain  and  distension  after  taking 
food,   flatulence,  and    hyperchlorhydria.     There   is   usually  obstinate 


ENTEROPTOSIS 

oonstipation ;  sometimes  symptoms  oi  mucous  colitis  develop.  En 
many  oases  all  the  genera]  Bymptoms  oi  neurasthenia  are  present  to 
a  marked  degree. 

« >n  examination  of  the  abdomen,  the  epigastrium  may  be  Been  to 
be  flattened,  while  the  Lower  part  <>f  the  abdomen  is  unduly  prominent. 
By  percussion,  both  holders  of  the  stomach  are  found  to  be  lower 
than  normally,  and  the  natural  downward  bend  <>[  the  tran 
(•ohm  is  greatly  exaggerated,  sometimes  to  such  an  extenl  that  the 
colon  reaches  the  pubes.  As  the  viscera  change  their  position  with 
the  attitude  assumed,  the  patient  should  be  examiued  successively 
in  the  recumbent,  the  knee-elbow,  and  the  erect  position.  The 
position  of  the  stomach  and  colon  may  be  demonstrated  by  X-ray 
examination  after  the  introduction  into  the  respective  viscera  of  an 
emulsion  of  bismuth. 

Treatment. — In  mild  cases,  great  benefit  follows  the  Weir- 
Mitehell  plan  of  treatment  for  the  general  neurasthenic  condition  ; 
and  massage,  electricity,  and  suitable  exercises  should  be  prescribed 
to  improve  the  tone  of  the  abdominal  muscles. 

The  lower  part  of  the  abdomen  should  be  supported  by  a  suitable 
belt  or  bandage,  applied  while  the  patient  is  in  the  Trendelenburg 
position,  and  exerting  pressure  from  below  upwards. 

In  aggravated  cases,  or  when  these  measures  have  failed,  operative 
treatment  may  be  considered,  but  when  the  neurasthenic  element  is 
prominent,  even  complete  restoration  of  the  viscera  to  their  normal 
position  often  fails  to  relieve  the  symptoms. 

Success  has  followed  slinging  up  the  stomach  by  "  reefing  "  the 
lesser  omentum.  The  stomach  and  transverse  colon  have  been  fixed 
to  the  abdominal  wall,  and  other  operations  have  been  performed  to 
restore  individual  viscera  to  their  proper  position.  It  is  probable 
that  when  benefit  follows  the  opening  of  the  abdomen  in  these  cases, 
it  is  largely  due  to  the  tightening  up  of  the  abdominal  wall  in  suturing 
it,  and  special  attention  should  always  be  directed  to  this  part  of  the 
procedure. 

Axbuthnot  Lane  recommends  ileo-colostomy  in  severe  and  per- 
sistent cases,  and,  when  pain  is  excessive,  excision  of  the  colon. 

ABNORMAL   ANUS 
An  opening  deliberately  made  in  the  bowel  to  enable  the  intestinal 
contents  to  escape  is  spoken  of  as  an  artificial  anus,  and  is  to  be  dis- 
tinguished from  a  /cecal  or  intestinal  fistula  which  results  from  injury 
or  disease. 

Artificial  Ax  us 
The  most  common  example  of  artificial  anus  is  that  made  in  the 
pelvic  colon  to  empty  the  bowel  when  it  is  obstructed  by  malignam 


452 


THE   INTESTINES 


disease  in  the  rectum  (Fig.  403).  Through  a  wound  in  the  parietes 
a  knuckle  of  the  pelvic  colon  is  brought  out,  and  fixed  by  a  glass 
rod  passed  through  its  mesentery.  An  opening  is  made  on  the 
convex  aspect  of  the  bowel,  with  the  result  that  both  the  afferent 
and  efferent  tubes  present  on  the  surface,  the  mesenteric  wall  of  the 
gut  forming  a  septum  or  "  spur  "  between  them,  which  directs  the 
flow  out  through  the  opening  and  prevents  the  contents  reaching 
the  distal  or  efferent  tube. 

As  a  rule,  such  an  artificial  anus  is  intended  to  be  permanent,  but 
similar  openings  are  frequently  made  in  this  and  other  parts  of  the 


Fig.  403. — Artificial  anus. 

bowel  as  a  temporary  expedient,  and  when  the  necessity  for  the 
opening  is  past  it  should  be  closed. 

The  main  difficulty  in  effecting  the  closure  arises  from  the  presence 
of  the  spur  between  the  afferent  and  efferent  loops.  This  may  be 
destroyed  by  crushing  it  between  the  blades  of  a  powerful  clamp  or 
"  enterotome."  The  septum  or  spur  is  defined  by  passing  a  finger 
into  each  of  the  tubes  of  bowel,  and,  one  blade  of  the  enterotome 
being  passed  along  each  finger,  the  spur  is  crushed  by  closing  the 
instrument.  It  is  then  supported  by  dressings  and  left  in  position 
till  it  causes  necrosis  of  the  spur  and  comes  away,  which  usually 
happens  in  two  to  four  days.  The  continuity  of  the  bowel  being  thus 
restored,  the  external  opening  gradually  closes. 

A  more  certain  and  expeditious  method  is  to  separate  the  bowel 
from  the  abdominal  wall  by  dissection,  and  invert  the  edges  of  the 
opening  by  sutures.  The  parietal  wound  is  then  closed.  If  it  appears 
that  the  invagination  of  the  opening  in  the  bowel  tends  to  narrow 
the  lumen  unduly,  it  is  better  to  resect  the  segment  implicated  and 
establish  a  lateral  anastomosis. 


EXTERNAL   I  IS  It  I.  .!•; 


•153 


External  Intestinal  ob  F.kiwl  Fistula 
An  external  01  faecal  fistula  is  an  abnormal  track  Leading  from  the 

lumen  of  the  bowel  to  t he  surface  of  the  skin,  ami  giving  <  x i t  to 
intestinal  contents.  As  ;i  rule,  the  opening  in  the  bowel  is  a  com- 
paratively small  one,  and,  so  long  as  the  lumen  of  the  gut  beyond  ifl 
unobstructed,  only  a  small  proportion  of  the  intestinal  contents  escapes 
to  the  surface. 

Causes — If  the  vitelline  duct  persists  as  a  pervious  tube  when 
the  umbilical  cord  separates  after  birth,  a  fistulous  track  is  left  in 
the  form  of  a  patent  Meckel's  diverticulum  (Fig.  398).     As  a  rule,  only 


Fig.  404. — Faecal  fistula  ;  bowel  adherent  to  parietal  peritoneum. 

a  small  quantity  of  clear  mucus  escapes  from  such  an  umbilical  fistula, 
and  the  discharge  may  cease  spontaneously,  or  after  the  lining  membrane 
of  the  track  has  been  destroyed  by  the  actual  cautery.  If  fsecal  matter 
escapes,  the  abdomen  should  be  opened  and  the  diverticulum  excised, 
the  orifice  of  communication  with  the  ileum  being  closed  by  suture. 

A  fistula  may  develop  after  injury  of  the  bowel  wall — for  example,  a 
contusion,  a  rupture,  or  a  penetrating  wound — or  as  a  result  of  intes- 
tinal sutures  having  given  way.  If  the  bowel  has  become  adherent 
to  the  parietal  peritoneum  before  the  fistula  forms,  the  channel  of 
communication  is  short  (Fig.  404),  and  is  often  lined  by  the  mucous 
membrane  of  the  gut,  which  may  even  protrude  from  the  opening. 
If,  on  the  other  hand,  an  abscess  has  developed  in  relation  to  the 
damaged  portion  of  bowel,  and  has  eventually  worked  its  way  to 
the  surface,  the  fistulous  track  may  be  of  considerable  length,  and 
is  lined  with  granulation  tissue,  which  yields  a  certain  amount  of 
pus  (Fig.  405). 


454 


THE   INTESTINES 


Fistulas  may  also  originate  in  ulceration  of  the  boioel,  such  as  some- 
times occurs  in  tuberculosis,  in  actinomycosis,  and  in  malignant 
disease  ;  or  from  suppurative  conditions  around  it,  notably  in  appen- 
dicitis with  sloughing  of  the  wall  of  the  caecum,  and  in  perforation 
of  the  gut  by  foreign  bodies.  Sometimes  the  inflamed  appendix  becomes 
adherent  to  the  parietes,  and  its  lumen  forms  the  track  of  the  fistula 
— a  condition  of  natural  appendicostomy. 

Clinical  features. — An  intestinal  fistula  may  be  met  with  any- 
where on  the  abdominal  wall,  and  it  is  not  always  easy  to  determine 


Fig.  405. — Fsecal  fistula  originating  deep  in  the  abdomen. 

the  part  of  the  bowel  with  which  it  communicates.  If  the  discharge 
is  fluid,  acid  in  reaction,  and  contains  bile  and  undigested  food,  and 
if,  further,  it  causes  irritation  and  superficial  ulceration  of  the  skin, 
the  opening  probably  leads  into  the  upper  part  of  the  jejunum.  This 
is  rendered  more  probable  if  the  patient  emaciates  rapidly  and  shows 
signs  of  starvation. 

The  discharge  from  a  fistula  opening  into  the  lower  part  of  the  small 
intestine  is  usually  neutral  or  alkaline  in  reaction,  and  is  less  irritating 
to  the  skin ;  bile  and  undigested  food  material  cannot  be  distinctly 
recognized. 

The  discharge  from  a  fistula  in  the  colon  is  distinctly  fsecal ;  in 
the  ceecum  it  may  be  fluid  and  contain  a  considerable  quantity  of 
mucus  ;   in  the  lower  parts  of  the  colon  it  is  solid  or  semi-solid. 


ENTESTINAL    FISTU1    l  455 

Treatment.  It  is  evidenl  thai  if  a  fistula  Is  associated  with 
some  irremovable  disease  oi  the  bowel,  such  as  carcinoma  or  tuber- 
culosis, no  attempt  need  be  made  to  close  it.  If,  on  the  other  band, 
it  has  resulted  from  some  condition  which  has  been  overcome,  such 
as  an  appendicular  abscess,  it  should  be  deall    with. 

It  is  to  be  borne  in  mind  that  those  fistulse  thai  are  lined  with 
granulation  tissue  show  a  marked  tendency  to  close  spontaneously 
so  long  as  the  bowel  beyond  is  unobstructed.  If,  after  a,  reasonable 
tune,  this  fails  to  take  place,  the  patient  should  be  confined  to  bed, 
the  diet  regulated  so  as  to  leave  a  minimum  of  residual  material  to 
pass  through,  and  the  granulation  tissue  gently  scraped  with  a  sharp 
spoon.  If  there  is  an  abscess  cavity  in  the  track  of  the  fistula,  this 
should  be  opened  up,  and  the  wound  packed  lightly  with  iodoform 
worsted  to  induce  it  to  heal  from  the  bottom.  Purgative  medicines 
should  be  avoided,  and  the  bowels  emptied  by  enemata  if  necessary. 

When  the  fistula  is  lined  by  mucous  membrane,  spontaneous  closure 
seldom  takes  place,  especially  if  there  is  a  double  loop  of  bowel  with 
an  intervening  spur  as  in  an  artificial  anus.  It  is  then  necessary  to 
separate  the  bowel  from  the  parietes  by  dissection,  and  to  invaginate 
the  aperture  by  sutures.  If  the  opening  is  a  large  one  and  its  closure 
by  invagination  unduly  narrows  the  lumen,  the  segment  of  bowel 
implicated  should  be  resected  and  a  lateral  anastomosis  made. 

Internal  Intestinal  Fistula 

As  a  result  of  disease,  particularly  in  malignant  and  tuberculous 
affections  of  the  abdomen,  fistulous  communications  are  occasionally 
established  between  the  intestine  and  other  viscera.  Sometimes  an 
adventitious  opening  forms  between  two  coils  of  bowel,  but  this  is 
serious  only  if  the  upper  opening  is  high  in  the  jejunum  and  the 
lower  one  well  down  the  bowel  ;  in  this  case  a  long  tract  of  the 
intestine  is  short-circuited,  and  is  lost  for  purposes  of  absorption, 
with  the  result  that  the  patient  rapidly  emaciates.  The  stools  may 
contain  unaltered  bile  and  imperfectly  digested  food  materials. 

A  communication  is  sometimes  established  between  the  stomach 
and  the  transverse  colon  as  a  result  of  malignant  disease  spreading 
from  one  of  these  organs  to  the  other.  Undigested  food  may  appear 
in  the  stools,  or  faecal  matter  may  be  vomited,  with  eructation  of 
intestinal  gases. 

In  malignant  or  tuberculous  disease  of  the  pelvic  colon  or  rectum, 
and  as  a  complication  of  chronic  inflammatory  diseases  of  the  colon 
associated  with  diverticula,  fistula?  may  form  with  the  bladder  or 
urethra.  This  not  only  causes  great  discomfort,  but  is  attended  with 
considerable  risk  to  life  from  the  spread  of  infection  to  the  kidneys. 

Operative  measures  for  the  closure  of  such  fistulae  are  attended 


456  THE   INTESTINES 

with  some  danger,  and  are  only  to  be  undertaken  when  the  condition 
is  endangering  life  and  there  is  a  reasonable  prospect  of  curing  the 
associated  disease.  The  prospect  of  being  able  to  cure  the  fistula  is 
greatest  when  it  has  originated  in  a  chronic  inflammatory  disease  of 
the  colon  with  diverticula,  which  is  now  known  to  be  the  commonest 
cause. 

INJURIES 

From  the  clinical  point  of  view,  it  is  convenient  to  divide  injuries 
of  the  bowel  into  (1)  those  that  are  subcutaneous,  and  (2)  open  wounds 
— for  example,  gunshot  injuries  or  stabs.  It  is  by  no  means  uncommon 
for  the  intestine  and  its  associated  processes  of  peritoneum  to  be 
damaged  by  external  violence  without  any  evidence  of  injury  to  the 
abdominal  parietes,  and  the  gravity  of  the  patient's  condition  only 
becomes  manifest  when  the  effects  of  the  injury  declare  themselves 
in  the  form  of  peritonitis,  or  by  symptoms  of  internal  haemorrhage. 
These  injuries  are  often  associated  with  lesions  of  other  viscera,  such 
as  rupture  of  the  liver,  spleen,  or  kidney,  or  intraperitoneal  rupture 
of  the  bladder. 

SUBCUTANEOUS   IXJUEIES 

Etiology. — For  purposes  of  diagnosis,  it  is  of  great  assistance 
to  obtain  an  accurate  description  of  the  accident,  as  the  lesion  pro- 
duced depends  to  a  large  extent  upon  the  nature,  intensity,  and 
direction  of  the  force  apphed. 

Subcutaneous  rupture  of  the  intestine  may  be  due  to  crushing, 
tearing,  or  bursting  forms  of  violence. 

Injuries  produced  by  crushing. — The  most  common  cause  of 
subcutaneous  injury  to  the  bowel  is  the  direct  impact  of  a  blunt 
object  against  the  anterior  abdominal  wall ;  for  example,  a  kick  from 
a  horse,  a  blow  with  the  fist,  or  a  fall  against  a  projecting  object.  The 
intestine,  deprived  for  the  moment  of  the  protection  of  the  abdominal 
muscles,  which  are  taken  unawares,  is  injured  by  being  nipped  between 
the  impinging  object  and  the  bodies  of  the  vertebrae.  The  centrally 
placed  coils  of  smaU  intestine — that  is,  those  in  the  vicinity  of  the 
umbilicus — are  most  exposed  to  such  forms  of  violence,  particularly 
if  the  force  is  acting  either  directly  backwards,  or  obhquely  from 
without  inwards.  If  the  force  acts  in  a  direction  away  from  the 
middle-line — downwards  and  outwards — the  colon  is  more  likely  to 
be  injured. 

Injuries  produced  by  tearing. — If  the  blow  is  a  glancing  one, 
acting  from  above,  or  if  the  body  is  squeezed,  say,  between  buffers  or 
by  a  wheel  passing  obhquely  over  it,  the  more  movable  segments  of  the 
bowel  are  driven  before  it,  while  the  fixed  portions,  particularly  the 
duodeno- jejunal  junction,  and  less  frequently  the  ileo-caecal  junction, 


INTESTINAL    INJURIES  4.57 

the  junction  of  the  descending  colon  with  the  pelvic  colon,  or  <>f  the 
pelvic  colon  with  the  rectum,  are  liable  to  be  torn  across.  Cases  are 
recorded  in  which  rupture  of  the  small  intestine  has  been  produced 

by  the  impact  of  a  bullet  which  grazed  the  abdominal  wall  without. 
penetrating  it.  The  mesentery  may  be  torn  from  the  bowel  for  a 
considerable  distance,  sometimes  for  several  inches. 

Injuries  produced  by  bursting.— (July  in  rare  cases  is  the 
bowel  burst  by  increased  intra-intcstinal  pressure  induced  by  violence 
applied  from  without.  This  may  occur  if,  for  the  moment,  both  ends 
of  a  coil  of  bowel  distended  with  gas  or  food  are  occluded,  and  severe 
force  is  brought  to  bear  on  the  full  loop.  It  goes  without  saying  that 
if  the  bowel  is  weakened  by  ulceration  it  is  more  liable  to  be  ruptured 
by  such  a  form  of  violence. 

Morbid  anatomy. — In  the  great  majority  of  cases,  the  small 
intestine  is  the  seat  of  rupture,  and,  as  a  rule,  the  bowel  gives  way 
only  at  one  point.  In  about  10  per  cent,  of  cases,  however,  it  is  torn 
at  several  points. 

The  wall  of  the  intestine  may  be  merely  contused,  blood  being 
effused  between  its  coats.  If  the  effusion  is  in  the  mucous  membrane, 
it  may  lead  to  haemorrhage  into  the  lumen,  with  blood-stained  stools  ; 
or  sloughing  of  the  mucous  membrane  may  ensue  and  lead  to  the 
formation  of  an  ulcer.  The  lowering  of  the  vitality  of  the  bowel  may 
admit  of  organisms  traversing  the  walls  and  setting  up  localized  peri- 
tonitis some  days  after  the  accident. 

If  only  one  or  other  of  the  coats  is  torn  through — incomplete  rupture 
— the  immediate  escape  of  the  intestinal  contents  is  prevented,  but 
peritonitis  may  subsequently  result,  either  from  necrosis  of  the  damaged 
portion  or  from  the  passage  of  organisms  through  it. 

When  all  the  coats  are  torn  through — complete  rupture — the  con- 
tents usually  escape  at  once  into  the  general  peritoneal  cavity,  and 
set  up  septic  peritonitis  ;  but  if  the  tear  is  small  and  the  bowel  is 
empty  at  the  time,  the  mucous-  membrane  may  protrude  and  plug 
it,  and  adhesions  form  with  the  omentum  or  with  adjacent  coils  and 
so  prevent  leakage.  The  circular  muscles  contract  and  so  help  to 
occlude  the  rupture,  and  it  is  possible  that  the  portion  of  the  bowel 
above  the  lesion  is  paralysed,  and  so  does  not  send  its  contents  on 
into  the  damaged  segment.  The  presence  of  peritonitis,  therefore, 
does  not  necessarily  connote  complete  rupture  of  the  bowel,  nor  does 
its  absence  necessarily  indicate  that  the  bowel  has  not  been  torn. 

The  colon  is  very  seldom  ruptured  by  direct  violence.  Berry 
and  Giuseppi  have  collected  132  cases  from  the  records  of  London 
hospitals  during  15  years  (1892-1907).  As  in  the  small  intestine,  the 
lesion  may  be  a  complete  tear  or  a  small  perforation,  and  the  devitalized 
bowel  may  subsequently  give  way  at  one  or  more  points. 


458  THE    INTESTINES 

Cases  are  recorded  in  which  those  portions  of  the  colon  with  an 
incomplete  mesentery  have  ruptured  into  the  retroperitoneal  tissues, 
giving  rise  to  localized  suppuration,  and  in  some  instances  to  surgical 
emphysema  from  the  escape  of  intestinal  gases.  The  colon  has  been 
ruptured  by  large  enemata  given  for  the  relief  of  constipation,  and 
by  foreign  bodies  entering  the  rectum. 

Clinical  features. — In  many  cases  it  is  evident  from  the 
general  appearance  of  the  patient  that  he  has  sustained  a  grave 
abdominal  injury,  while  in  others,  with  equally  severe  lesions,  there 
is  nothing  to  cause  anxiety.  The  three  symptoms  most  constantly 
present,  which  strongly  suggest  perforation  of  the  bowel,  are  pain, 
vomiting,  and  muscular  rigidity. 

The  pain  is  usually  severe  and  persistent,  and  is  more  or  less  diffused 
over  the  belly,  but  it  is  most  intense  at  the  site  of  the  visceral  lesion. 
Tenderness  on  palpation  also  is  usually  most  marked  over  the  rupture. 

Vomiting  often  comes  on  at  the  time  of  the  injury,  continues  after 
the  stomach  has  emptied  itself  of  food,  and  is  attended  by  nausea. 
The  presence  of  blood  in  the  vomit  indicates  that  the  stomach  or 
duodenum  is  the  seat  of  the  injury.  If  the  vomit  is  bilious,  the  small 
intestine  is  probably  injured.  With  the  onset  of  peritonitis,  the 
vomiting  assumes  the  characteristic  gulping  character. 

Muscular  rigidity  is  the  most  valuable  and  characteristic  sign, 
especially  when  accompanied  by  tenderness.  The  fixation  of  the 
abdominal  walls,  and  the  restricted  action  of  the  diaphragm,  render 
the  respiration  almost  entirely  thoracic. 

At  first  the  abdomen  is  retracted  to  the  extent  of  being  scaphoid, 
but  later  it  becomes  prominent,  either  from  paralytic  distension  of 
the  bowel,  or  from  the  escape  of  gas  into  the  peritoneal  cavity.  The 
early  onset  of  tympanites  is  very  significant  of  a  rupture  of  the  bowel. 

Shock  is  sometimes  so  severe  as  to  prove  fatal  within  a  few 
minutes  ;  in  other  cases  it  is  slight  and  evanescent.  As  a  rule,  all 
the  classical  symptoms  of  shock  are  present,  but  in  quite  a  number 
of  cases  the  patient  has  shown  none,  and  has  continued  to  work  for 
some  hours  and  been  able  to  walk  home  or  to  the  hospital  before  he 
began  to  feel  ill.  In  these  cases,  the  first  sign  of  the  injury  is  the 
onset  of  peritonitis. 

Dullness  in  the  flank  may  be  due  to  empty,  contracted  bowel, 
or  to  extra vasated  blood,  but  it  is  not  a  reliable  symptom,  as  the  rigidity 
of  the  abdominal  muscles  may  prevent  its  recognition.  If  the  dullness 
changes  with  the  position  of  the  patient,  it  is  usually  due  to  fluid 
blood  or  urine  in  the  peritoneal  cavity.  The  dullness  from  fluid  blood 
is  usually  most  marked  above  the  pubes. 

The  diminution  of  the  area  of  liver  dullness  from  the  escape  of 
gas  into  the  peritoneal  cavity  is  of  no  value,  and  this  symptom  should 


INTESTINAL   INJURIES  459 

be  ignored  in  forming  a  diagnosis,  as  it  may  \><-  due  to  gaseous  dis- 
tension of  the  colon  displacing  the  liver.  Emphysema  of  the  subperi- 
toneal tissue  is  ran\  ezcepl  in  cases  of  rupture  at  the  duodeno-jejunal 
junction,  or  of  the  colon  behind  the  peritoneum. 

In  the  rarlv  stages  the  pulse  has  the  character   associated  with 
shock,  and,  in  the  later    stages,  that    associated  with  peritonitis.     A 
rapid   rise  in  the  pulse-rate,  especially  if  associated  with  a  ri 
temperature  to  103°  or  104°  F.,  is  usually  of  bad  omen,  as  is  also  per- 
sistence of  rapid,  superficial  breathing. 

Inability  to  pass  faeces  or  flatus  is  usually  present,  but  the  patient 
often  empties  the  lower  bowel  soon  after  the  accident,  and  if  the 
motion  contains  blood,  an  injury  to  the  bowel  is  strongly  suggested. 

Even  after  a  careful  analysis  of  all  the  symptoms  it  is  often 
impossible  to  be  certain  whether  or  not  the  bowel  has  been  ruptured, 
and  it  is  seldom  possible  to  localize  the  seat  of  the  lesion  when  present. 

Treatment. — When  the  nature  of  the  accident  and  the  symp- 
toms presented  by  the  patient  render  it  probable  that  the  intestine 
has  been  damaged,  an  exploratory  operation  should  be  performed, 
even  although  there  is  no  conclusive  evidence  of  visceral  injury. 
Experience  has  shown  that  in  many  of  these  cases  it  is  only  when 
signs  of  peritonitis  develop  that  a  positive  diagnosis  can  be  made, 
and  that  operations  carried  out  then  are  comparatively  seldom 
successful.  The  best  results  have  followed  operations  performed 
between  seven  and  twelve  hours  after  the  accident,  in  the  interval 
between  the  passing  off  of  the  initial  shock  and  the  onset  of  peritonitis. 

The  abdomen  is  opened  over  the  seat  of  injury  if  this  can  be 
determined,  and  the  lesion  in  the  bowel  or  blocd-vessels  sought  for 
and  dealt  with.  If  a  single  tear  is  found,  it  is  closed  by  Lembert 
sutures  inserted  at  right  angles  to  the  long  axis  of  the  gut.  More 
extensive  lesions  necessitate  resection  of  portions  of  the  bowel,  with 
lateral  anastomosis.  The  peritoneum  is  then  cleansed,  and  the 
abdomen  closed,  with  or  without  drainage  as  may  be  found  necessary. 

OPEN    WOUNDS 
Stab  Wounds 

The  presence  of  a  penetrating  wound  of  the  abdominal  wall  always 
raises  the  presumption  of  a  punctured  or  incised  wound  of  the  intestine. 
If  the  puncture  in  the  bowel  is  a  small  one,  the  contraction  of  the 
muscular  coat  may  close  it,  or  the  mucous  membrane  may  protrude 
and  prevent  the  escape  of  intestinal  contents. 

Nothing  can  be  learnt  by  exploring  the  external  wound  with  the 
probe,  and  this  procedure  is  dangerous  in  that  it  may  introduce  infec- 
tive material  deeper  into  the  tissues,  or  may  determine  an  escape  of 


460  THE   INTESTINES 

intestinal  contents  by  opening  up  a  puncture  which  has  been  closed 
by  natural  means,  or  sealed  off  by  fibrinous  exudate. 

The  clinical  features  are  similar  to  those  of  subcutaneous 
rupture  (p.  458),  and  the  external  wound  indicates  the  site  of  the 
injured  loop  of  bowel,  which  is  almost  invariably  immediately  beneath 
the  wound  in  the  parietes. 

The  escape  of  gas  or  fseces,  or  the  protrusion  of  the  damaged  loop 
of  bowel  through  the  external  wound,  removes  all  doubt  as  to  the 
diagnosis,  but  in  the  absence  of  these  signs  it  is  often  extremely 
difficult  to  decide  whether  the  bowel  has  been  injured  or  not.  If 
the  nature  of  the  accident,  the  length  and  character  of  the  weapon, 
and  the  position  of  the  external  wound  render  it  probable  that  the 
bowel  has  been  injured,  an  exploratory  operation  should  always  be 
performed  at  once.  The  existing  wound  is  opened  up  and  purified, 
the  underlying  coils  of  bowel  examined,  and  any  lesions  found  dealt 
with.  If  the  puncture  is  small  and  single,  it  may  be  closed  by  a  Lem- 
bert  suture,  introduced  at  right  angles  to  the  long  axis  of  the  bowel ; 
if  more  extensive,  it  may  be  necessary  to  resect  a  portion  of  the  gut 
and  establish  a  lateral  anastomosis.  A  considerable  length  of  the 
bowel  should  be  examined,  as  there  may  be  more  than  one  wound. 
The  peritoneum  is  cleansed  and  the  parietal  wound  closed,  suitable 
provision  being  made  for  drainage.  For  the  first  few  days  the  patient 
should  be  kept  in  the  Fowler  position. 

Gunshot  "Wounds 

The  experience  of  military  surgeons  in  warfare  goes  to  show  that 
injuries  of  the  intestine  produced  by  modern  small-bore  bullets  are 
much  less  serious  than  were  those  due  to  the  older  and  larger  missiles. 
The  puncture  in  the  bowel  made  by  a  high-velocity  conical  bullet 
is  extremely  minute,  and  the  mucous  membrane  protrudes  and  closes 
the  aperture  ;  and,  as  the  peristalsis  is  immediately  arrested  by  the 
shock,  time  is  given  for  plastic  lymph  to  be  effused  and  adhesions 
to  form  between  adjacent  coils  of  intestine,  or  with  a  tag  of  omentum, 
before  intestinal  contents  pass  along  the  damaged  segment,  and  thus 
leakage  is  prevented.  This  is  the  more  likely  to  occur  as  the  patient 
has  often  been  fasting  for  some  hours  before  being  wounded. 

The  patient  should,  as  far  as  possible,  be  left  undisturbed  for  some 
hours  after  being  wounded,  in  order  that  the  formation  of  plastic 
lymph  may  not  be  interfered  with.  On  no  account  should  the  wound 
be  probed.  In  the  South  African  War  about  one-third  of  the  cases  of 
injury  of  the  small  intestine,  and  about  two-thirds  of  the  cases  of 
injury  of  the  colon,  recovered  without  operation.  Operative  inter- 
ference should  not  be  delayed  if  there  is  evidence  of  infection  of  the 
peritoneum  or  of  severe  internal  hemorrhage. 


INJURIES  OF  THE   MISI  \  l  ikv  461 

Pistol-shot  wounds  and  wounds  by  Bpoiting  gone  are  more  <•  m- 
mon  in  civil  practice,  and  in  their  clinical  aspects  they  resemble 
the  injuries  produced  by  pointed  instruments  rather  than  gunshol 
wounds.  The  intestinal  injury  is  a  contused  and  lacerated  wound, 
and  often,  from  the  scattering  of  small  shot,  or  from  the  close 
range  at  which  the  weapon  was  discharged,  several  coils  of  bowel 
are  damaged. 

The  point  of  entrance  of  the  bullet  may  be  extremely  minute. 
In  one  case  operated  upon  by  me,  it  was  only  discovered  on  opening 
up  the  folds  of  the  umbilical  cicatrix. 

There  may  be  considerable  hsomorrhage  into  the  peritoneal  cavity 
from  injury  to  a  vessel  in  the  abdominal  wall,  such  as  the  deep  epi- 
gastric, or  from  injury  to  the  mesenteric  vessels. 

The  treatment  of  gunshot  or  pistol-shot  wounds  consists  in 
opening  up  the  wound  of  entrance,  and  examining  the  whole  length 
of  the  bowel.  Each  puncture  is  closed,  and  any  contused  area  of 
bowel  invaginated  by  a  purse-string  suture  to  prevent  the  risk  of 
subsequent  necrosis  and  leakage.  It  is  not  necessary  to  search  for 
the  bullet,  which  is  usually  embedded  in  bone  or  muscular  tissue, 
where  it  does  no  barm. 

INJURIES   OF   THE   MESENTERY 

The  mesentery  may  be  ruptured  by  violence  inflicted  on  the 
anterior  abdominal  wall,  or  by  penetrating  wounds.  Many  of  the 
fatal  cases  of  gunshot  wound  of  the  abdomen  occurring  in  warfare 
are  due  to  injuries  of  the  mesenteric  and  omental  blood-vessels.  As 
a  rule  other  viscera  are  also  implicated. 

Profuse  haemorrhage  usually  takes  place  into  the  peritoneal  cavity, 
with  a  rapidly  fatal  result.  Sometimes  the  blood  is  effused  between 
the  leaves  of  the  mesentery  and  forms  a  localized  ha?matoma.  In 
a  case  of  this  kind  operated  upon  by  me,  a  cake-like  mass  of  clotted 
blood,  about  the  size  of  the  palm  of  the  hand  and  nearly  an  inch 
thick,  was  found  in  the  mesentery  of  a  boy  aged  13,  about  sixty 
hours  after  he  bad  sustained  a  blow  in  the  umbilical  region.  The 
clot  was  turned  out,  and  the  boy  recovered. 

The  damage  to  the  vessels  may  so  interfere  with  the  vascularity 
of  the  bowel  that  gangrene  of  the  loop  implicated  ensues,  and  leads 
to  a  fatal  result  from  peritonitis. 

The  symptoms  resemble  those  of  contusion  or  rupture  of  the  bowel, 
but  the  signs  of  internal  haemorrhage  are  superadded. 

The  only  treatment  is  to  open  the  abdomen  and  secure  the 
vessels.  The  tear  in  the  mesentery  should  be  closed,  lest  it  form  an 
aperture  through  which  the  bowel  may  subsequently  pass  and  be 
strangulated. 


462  THE   INTESTINES 

FOREIGN    BODIES   IN   THE   INTESTINE 

The  great  majority  of  foreign  bodies  that  have  been  swallowed 
and  have  successfully  passed  the  pylorus,  safely  traverse  the  remaining 
segments  of  the  alimentary  canal  and  are  passed  by  the  rectum.  The 
facility  with  which  large  and  irregular  objects  pass  along  the  intestinal 
canal  is  remarkable. 

In  its  passage  along  the  bowel,  a  foreign  body  may  become  encrusted 
with  fa?cal  matter  and  phosphates,  and,  while  this  may  add  to  the 
bulk  of  the  object,  it  at  the  same  time  renders  its  passage  safer  by 
rounding  off  sharp  angles  or  filling  up  crevices  and  hooks,  as,  for 
example,  in  the  case  of  a  small  tooth-plate.  Some  metallic  objects 
undergo  a  certain  degree  of  solution,  while  organic  bodies,  such  as 
bones,  may  be  partly  digested. 

Clinical  features. — The  passage  of  a  foreign  body  along 
the  intestine  is  seldom  attended  with  any  symptoms  beyond  slight 
colicky  pain  and  occasional  vomiting.  The  time  taken  for  an  insoluble 
body  to  traverse  the  bowel  varies  from  forty-eight  hours  to  two  or 
three  weeks.  Irregular  bodies  are  sometimes  temporarily  arrested 
and  cause  localized  irritation  of  the  mucous  membrane  with  symptoms 
of  enteritis,  in  the  form  of  fever,  severe  griping  pain  and  tenderness, 
distension,  and  diarrhoea,  with  pus  and  blood  in  the  stools. 

As  the  most  common  site  of  arrest  is  in  the  lower  part  of  the  ileum, 
at  the  ileo-csecal  valve,  or  in  the  caecum,  the  local  symptoms  are 
generally  referred  to  the  right  iliac  fossa.  If  the  body  is  long 
detained,  localized  peritonitis  may  ensue  with  muscular  rigidity  of 
the  abdominal  wall  over  the  site  of  arrest.  Foreign  bodies  may  be 
permanently  arrested  at  the  narrowest  part  of  the  gut — that  is,  the 
ileo-caecal  region — or  by  a  stricture  of  the  bowel,  the  most  common 
cause  of  which  is  malignant  disease  of  the  colon.  In  a  few  recorded 
cases,  a  foreign  body  has  been  arrested  in  a  hernia,  or  in  a  pouch  or 
diverticulum  of  the  bowel. 

Only  in  very  rare  cases  does  a  foreign  body  arrested  in  a  normal 
portion  of  the  bowel  cause  obstruction,  but  when  the  lumen  is  narrowed 
by  disease  and  becomes  occluded  by  an  object,  such  as  a  fruit- 
stone,  a  piece  of  bone,  or  a  gall-stone,  acute  symptoms  may  supervene. 
The  more  serious  effects  of  permanent  arrest  are  due  to  septic  com- 
plications following  enteritis  and  ulceration,  and  ending  in  perforation. 
Cases  have  been  recorded  in  which  localized  peritonitis  has  led  to 
abscess  formation,  and  the  foreign  body  has  passed  into  the  abscess 
and  escaped  through  the  abdominal  wall.  In  other  cases  the  object 
has  found  its  way  into  the  bladder  or  other  viscus. 

Treatment. — To  facilitate  the  passage  of  a  foreign  body  along 
the  intestine,  the  patient  should  be  fed  on  such  foods  as  porridge, 


INTESTINAL   OBSTRUCTION  463 

pease-brose,  01  vegetables,  which  Leave  a  considerable  residue,  In 
the  case  of  Buch  bodies  as  tooth-plates,  small  Lockets,  or  other  objects 
with  hooks  or  projections,  it  has  been  found  useful  to  mix  with  the 
food  a  moderate  quantity  of  ohopped-up  string,  which,  by  the  churning 

action  of  the  Btomach,  is  wound  round  thf  projections  ami  prevents 
them  catching  on  the  mucous  membrane.  In  tin-  greal  majority  of 
oases,  t  licic  is  no  call  to  operate,  unless  serious  symptoms  develop. 
If  a  skiagram  is  taken  to  locate  the  foreign  body  ami  operation  is 
decided  upon,  this  should  be  done  at  once,  as  the  body  may  change 
its   position  if  there  is  any  delay. 

INTESTINAL   OBSTRUCTION  ' 

Tho  term  "intestinal  obstruction"  is  a  purely  clinical  one,  ami 
implies  an  interference  with  the  passage  of  the  bowel  contents  along 
the  canal.  The  extent  of  the  arrest  varies  widely,  from  a  slight  diffi- 
culty in  obtaining  a  regular  evacuation  to  sudden  and  complete  arrest 
of  the  passage  of  faeces  and  flatus. 

The  primary  cause  of  the  obstruction  is  usually  mechanical,  and 
several  different  mechanisms  may  be  responsible.  For  example,  the 
lumen  may  be  gradually  narrowed  by  cicatricial  contraction,  resulting 
in  a  variable  degree  of  stenosis  or  stricture  ;  the  bowel  may  be  blocked 
by  a  tumour  of  the  wall  gradually  filling  it  up  ;  or  one  segment  of 
bowel  may  be  invaginated  into  another,  as  in  intussusception.  A\  ben 
due  to  such  causes  the  obstruction  is  incomplete  but  progressive. 
Again,  a  loop  of  bowel  may  be  twisted  on  its  mesenteric  axis,  as  in 
volvulus  ;  or  be  snared  by  a  fibrous  band,  the  margins  of  an  aperture 
in  the  mesentery,  or  the  neck  of  a  hernial  sac.  Under  these  conditions, 
not  only  is  the  lumen  immediately  occluded,  and  the  obstruction  at 
once  rendered  complete,  but  the  blood-vessels  of  the  segment  implicated 
are  also  occluded,  and  the  nerve  supply  interfered  with,  so  that  the 
vitality  of  the  bowel  is  endangered.  To  this  condition,  the  term 
"  strangulation  "  is  applied. 

Whatever  the  mechanical  cause  may  be,  sooner  or  later  the  nerve 
mechanism  governing  the  peristaltic  action  of  the  bowel  is  interfered 
with,  and  a  paralytic  factor  comes  into  play,  adding  to  the  difficulty 
the  bowel  has  in  emptying  itself. 

In  certain  forms  of  obstruction,  notably  that  associated  with 
generalized  peritonitis,  the  cause  is  inherent  in  the  bowel  itself,  con- 
sisting in  a  loss  of  muscular  contractility — paralytic  obstruction. 

It  is  convenient  to  classify  cases  of  obstruction  of  the  bowel  under 
the  headings— (1)  Acute  or  Sudden  Obstruction ;  (2)  Chronic  or 
Gradual  Obstruction  ;    and  (3)  Chronic  Obstruction  becoming  Acute. 

1  I  desire  here  to  express  my  indebtedness  to  the  writings  of  the  late 
H.  L.  Barnard. 


464  THE   INTESTINES 

1.  Acute  or  Suddex  Obstructiox 

Acute  obstruction  is  always  a  serious  condition,  and  is  attended 
by  a  group  of  symptoms  of  which  the  most  obvious  are  abdominal 
pain,  persistent  vomiting,  distension  with  complete  cessation  of  the 
passage  of  intestinal  contents,  and  a  greater  or  less  degree  of  shock. 
The  earliest  of  these  symptoms — pain,  vomiting,  and  shock — are  not 
peculiar  to  obstruction,  but  are  common  to  all  acute  abdominal 
affections,  and  are  probably  attributable  to  a  profound  impression 
made  upon  the  sensory  nerves  of  the  abdomen  rather  than  to  the  mere 
interference  with  the  transmission  of  the  bowel  contents. 

After  the  obstruction  has  lasted  for  some  time,  the  patient  passes 
into  a  condition  of  collapse  and  the  general  circulation  is  profoundly 
affected,  the  heart's  action  becoming  weak  and  rapid  as  a  result 
of  the  absorption  of  toxic  material  from  the  stagnating  contents  of 
the  bowel  above  the  seat  of  the  block.  At  this  stage,  the  relief  of 
the  obstruction  may  not  suffice  to  save  the  life  of  the  patient,  as  the 
amount  of  poisonous  material  absorbed  may  be  so  great  as  to  prove 
fatal.  It  is  evident,  therefore,  that,  once  a  diagnosis  of  obstruction 
has  been  made,  operative  treatment  should  be  undertaken  at  the 
earliest  possible  moment,  to  prevent  the  patient  absorbing  a  fatal  dose 
of  toxins,  and  that  no  operation  is  complete  that  does  not  ensure  a 
speedy  evacuation  of  the  segment  above  the  block  so  that  no  further 
absorption  may  take  place. 

Pathology  and  morbid  anatomy. — The  most  severe  forms 
of  acute  obstruction  are  those  due  to  sudden  and  complete  occlusion 
of  the  bowel,  as  when  a  loop  is  impacted  in  a  hernial  aperture,  or  is 
snared  by  a  band,  or  rotated  on  its  mesentery,  because  not  only  is 
the  passage  of  flatus  and  fseces  completely  arrested,  but  the  vessels 
supplying  the  strangulated  segment  are  occluded  and  the  nerve  supply 
interfered  with. 

The  immediate  effect  of  the  strangulation  is  to  excite  a  violent 
peristalsis,  which  results  in  forcing  on  the  contents  of  the  segment  below 
the  obstruction,  so  that  this  portion  is  emptied  and  passes  into  a  con- 
dition of  spasm.  When  seen  a  few  hours  after  obstruction  has  begun, 
it  is  pale,  contracted,  and  empty  ;  and  when  handled,  it  feels  firm. 
It  is  neither  collapsed  nor  paralysed. 

The  segment  above  the  obstruction  rapidly  becomes  distended  with 
intestinal  fluids  and  gases.  The  fluids  consist  of  liquid  faeces,  an 
excessive  secretion  of  the  glands  of  the  alimentary  canal,  inflamma- 
tory exudate,  and  blood.  When  the  disturbance  of  the  circulation 
is  so  great  as  to  interfere  with  absorption  of  gas  from  the  intestine, 
the  distension  is  added  to  by  accumulation  of  flatus  and  by  bac- 
terial decomposition  of  the  intestinal  contents.  At  first,  the  walls 
are  thin  and  pale,  but  in  the  course  of  a  few  hours  they  become 


I.. 


ACUTE   OBSTRUCTION  405 

deeply  congested  and  oedematous,  and  the  mucous  membrane  m 
show  haemorrhages  and  superficial  erosions. 

1  >i-t ensi»»ii  is  greatest  when  the  Bmall  intestine  ia  obstructed, 
because  Becretion  of  a  considerable  amount  of  fluid  is  reflexly  stimu- 
lated. The  distension  gradually  Bpreads  upwards  and  may  reach  the 
duodenum  or  even  the  Btomach.  When  the  pelvic  colon  is  the  seal 
of  the  obstruction,  the  distension  is  less,  because  the  higher  reaches 
of  the  colon  continue  to  absorb  fluid. 

In  course  oi  time,  the  surface  epithelium  of  the  mucous  membrane 
is  shed,  and  organisms  pass  through  the  wall  and  reach  the  peritoneal 
cavity,  giving  rise  to  peritonitis.  Minute,  sharply  circumscribed  ulcers 
may  form  as  a  result  of  necrosis  of  the  mucous  membrane,  and  these 
may  lead  to  perforation  (Kocher).  Sometimes  there  are  multiple 
pin-point  perforations  scattered  over  a  segment  of  bowel. 

The  strangulated  coil  becomes  deeply  congested  from  interference 
with  its  venous  return.  At  first,  unless  the  strangulation  is  very 
tight,  the  arteries  are  not  occluded,  and  they  continue  to  force  blood 
into  the  veins,  with  the  result  that  the  congestion  is  increased.  The 
bowel  becomes  deep  purple  in  colour,  tense  and  oedematous,  and 
blood-stained  serum  exudes  into  the  lumen  and  the  peritoneal  cavity. 

If  the  strangulation  is  so  acute  as  to  occlude  the  arteries  at  once, 
the  affected  segment  is  pale,  grey  or  green,  and  flaccid,  and  it  becomes 
gangrenous  within  a  few  hours.  The  occluded  segment  is  distended 
with  gas,  which  is  probably  carbonic  dioxide  that  cannot  be  absorbed 
by  the  veins,  and  the  distension  may  be  enormous — for  example,  in 
volvulus  of  the  pelvic  colon.  The  tension  of  the  strangulated  coil 
is,  as  a  rule,  much  greater  than  that  of  the  distended  bowel  above  the 
obstruction.  The  strangulated  loop  soon  loses  its  power  of  pre- 
venting organisms  passing  through  its  wall,  and  in  this  way  early 
infection  of  the  peritoneum  may  take  place.  Sooner  or  later  gangrene 
ensues  from  thrombosis  of  the  vessels,  and  perforations  of  various 
sizes  occur,  leading  to  peritonitis. 

Clinical  features. — The  clinical  features  of  acute  obstruc- 
tion vary  considerably  according  to  the  cause,  but  certain  symptoms 
are  common  to  all  cases,  whatever  the  cause,  and  these  may  be  con- 
sidered here. 

It  is  to  be  borne  in  mind  that  obstruction  itself  is  not  the  essential 
or  all-important  cause  of  the  symptoms.  The  initial  symptoms  are 
evidence  of  ':  peritonism,"  or  shock  inflicted  through  the  peritoneum  ; 
the  next  to  follow  are  due  to  interference  with  the  onflow  of  the 
intestinal  contents  ;  those  of  the  later  stages  are  signs  of  the  absorption 
of  toxins  from  the  stagnating  contents  or  from  peritonitis. 

As  a  rule,  the  onset  is  sudden,  the  patient  having  had  no  previous 
discomfort  or  feeling  of  illness,  and  it  is  seldom  possible  to  attribute 


466  THE   INTESTINES 

the  condition  to  any  exciting  cause.  The  first  symptom  is  intense 
abdominal  pain,  which  is  usually  so  severe  as  to  double  the  patient 
up,  or  cause  him  to  writhe  in  agony  on  the  floor.  When  the  small 
intestine  is  implicated,  the  pain  is  continuous,  and  is  referred  to  the 
region  of  the  umbilicus.  The  higher  up  in  the  intestine  the  strangu- 
lation occurs,  the  tighter  the  constriction,  and  the  greater  the  extent 
of  bowel  implicated  the  more  severe  is  the  pain.  When  the  obstruc- 
tion is  in  the  more  fixed  parts  of  the  bowel,  such  as  the  duodeno- 
jejunal junction,  the  ileo-caecal  junction,  or  the  colon,  the  pain  is 
usually  correctly  located  in  the  affected  segment. 

After  a  time,  when  the  nerves  of  the  strangulated  segment  become 
exhausted,  or  when  perforation  occurs  and  the  tension  in  the  loop 
is  relieved  by  the  escape  of  gas  and  fluid,  this  initial  pain  may 
be  temporarily  alleviated. 

Sooner  or  later,  however,  severe  griping  pain  is  experienced  from 
the  excessive  peristaltic  efforts  of  the  bowel  to  force  its  contents  along 
the  tube.  As  the  muscular  coats  become  exhausted,  this  pain  to  some 
extent  abates,  and  the  relief  may  be  contributed  to  by  the  poison- 
ing of  the  nerve  mechanism  with  toxins  derived  from  the  stagnating 
contents.  The  paralysis  thus  induced  may  prevent  the  bowel  from 
emptying  itself  even  if  the  obstruction  is  removed.  Up  to  this  point, 
the  pain  is  not  increased,  and  may  even  be  relieved,  by  pressure,  and 
there  is  no  marked  rigidity  of  the  abdominal  muscles. 

Unless  the  obstruction  is  relieved,  organisms  pass  through  the 
wall  of  the  gut  and  set  up  peritonitis,  and  this  is  associated  with  a 
characteristic  stabbing  pain,  which  is  increased  by  pressure,  and 
attended  by  rigidity  of  the  abdominal  muscles.  In  cases  of  extreme 
toxaemia,  the  abdominal  muscles  may  relax  and  the  tenderness  dis- 
appear— symptoms  of  grave  omen. 

Vomiting  almost  always  commences  within  a  few  hours  of  the 
onset  of  the  pain.  This  early  vomiting  is  a  reflex  symptom  due  to 
interference  with  the  sympathetic  nervous  system,  and  is,  as  a  rule, 
proportionate  to  the  severity  of  the  pain.  It  is  attended  with  nausea, 
retching,  and  eructation,  and  affords  no  relief  to  the  patient's  suffer- 
ing. It  occurs  independently  of  the  taking  of  food,  and  is  continuous 
and  persistent.  The  vomited  matter  consists  at  first  of  the  stomach 
contents  ;  later,  it  contains  a  large  admixture  of  bile,  which  appears 
to  be  excreted  in  excessive  quantities,  and  is  permitted  to  enter  the 
n.  stomach  by  the  relaxation  of  the  pylorus  induced  by  the  alkalinity 
,  of  the  bile  (Pavlov).  As  time  goes  on,  the  character  of  the  vomiting 
changes,  and  assumes  the  characteristic  regurgitant  or  gushing  type, 
in  which  mouthfuls  of  dark-brown  or  yellowish  fluid  are  brought  up 
without  retching  or  effort  The  fluid  has  a  highly  offensive  odour 
resembling  that  of  faeces,  but  is  not  really  fa3Cal  in  character.     The 


ACUTE   OBSTRUCTION:    SYMPTOMS 

odoui  is  due  to  bacterial  decomposition  of  the  intestinal  Quids  accumu- 
lated above  the  obstruction,  and  may  be  as  marked  in  cases  in  which 
the  obstruction  is  high  up  in  tin'  jejunum  as  in  obstruction  of  the 
large  intestine.  In  Eact,  cegurgitanl  vomiting  occurs  earlier  and  is 
more  severe  the  nearer  the  obstruction  is  to  the  Btomach,  and  it  La 
often  entirely  absent  when  the  colon  is  the  scut  of  the  obstruction. 

The  third  symptom  characteristic  of  the  onsel  of  acute  obstruction 
is  shock,  which  is  usually  well  marked  within  a  tew  hours,  and  is  .it 
first  ilue  to  the  profound  impression  made  upon  the  sympathetic  and 
other  nerve  fibres  distributed  in  the  abdomen.  Liter,  the  patienl 
passes  into  a,  condition  of  collapse,  which  is  aggravated  by  t he  loss  of 
fluid  from  persistent  vomiting  and  sweating,  and  by  intoxication  from 
absorption  of  toxins  formed  in  the  decomposing  contents  of  the  bowel 
above  the  obstruction.  The  face  is  pale,  the  eyes  are  sunken,  the  pulse 
is  rapid,  Eeeble,  and  thready,  the  respiration  shallow  and  sighing,  and 
the  temperature  persistently  subnormal.  The  skin  is  covered  with 
a  cold,  clammy  sweat.  The  hands,  the  feet,  and  the  tips  of  the  nose 
and  ears  become  cold,  blue,  and  shrivelled,  and  there  is  persistent, 
insatiable  thirst.  The  patient  often  suffers  greatly  from  cramps, 
especially  in  the  calf  muscles.  He  usually  remains  conscious  ;  indeed, 
is  often  abnormally  alert,  even  to  the  very  end,  and  fails  to  realize 
the  gravity  of  his  condition. 

Frequently  a  motion  is  passed  just  after  the  onset  of  pain  and 
vomiting,  the  lower  bowel  being  emptied  by  spasmodic  contraction 
of  the  segment  below  the  obstruction.  Thereafter  there  is  complete 
arrest  of  the  passage  of  faeces  and  flatus,  and  the  patient  has 
no  desire  to  defsecate,  except  in  those  cases  in  which  the  bowel  is 
strangulated  low  down,  when  there  may  be  tenesmus.  Enemata 
are  often  retained,  and  if  returned  the  fluid  flows  away  without  force 
and  unaccompanied  by  fseces  or  flatus. 

The  presence  of  indican  in  the  urine  is  fairly  common  in  cases 
of  acute  obstruction,  but  it  is  not  characteristic  of  this  condition,  as 
it  may  be  a  symptom  of  other  acute  affections.  It  is  due  to  bacterial 
decomposition  of  proteins,  resulting  in  the  formation  of  indol  in  the 
small  intestine,  which  is  excreted  by  the  kidney  as  indican.  This 
symptom  is  most  marked  in  obstruction  of  the  small  ^intestine,  and 
is  generally  not  present  till  the  second  or  third  day. 

An  examination  of  the  abdomen  in  the  early  stages,  as  a  rule, 
gives  little  information.  The  belly  is  usually  flat,  flaccid,  and  not 
tender.  Later,  it  is  more  prominent,  and  when  peritonitis  begins 
it  becomes  rigid. 

Tympanites  occurs  to  a  greater  or  less  extent  in  all  forms  of 
acute  obstruction,  but  is  most  marked  in  obstruction  of  the  large 
intestine,    particularly    in    volvulus  of   the  pelvic   colon.     Distension 


468  THE    INTESTINES 

of  a  single  loop  of  bowel  is  of  no  value  in  localizing  the  seat  of 
the  obstruction. 

In  primary  acute  obstruction,  peristaltic  waves  are  seldom  visible, 
unless  the  patient  is  extremely  emaciated.  In  the  acute  phase  of 
a  gradually  increasing  obstruction,  they  are  often  prominent  and  of 
diagnostic  value. 

Except  in  cases  of  intussusception,  or  of  obstruction  by  foreign 
bodies  or  fsecal  concretions,  a  localized  tumour  can  rarely  be  palpated 
in  the  abdomen. 

Differential  diagnosis. — The  initial  symptoms  of  acute  in- 
testinal obstruction  so  closely  resemble  those  of  other  acute  abdo- 
minal conditions  that  it  may  be  extremely  difficult  to  distinguish 
between  them.  Among  the  possibilities  that  have  to  be  considered 
at  this  stage  are  :  (1)  Acute  appendicitis,  (2)  perforation  of  a  gastric 
or  duodenal  ulcer,  (3)  rupture  of  a  pyosalpinx  or  extra-uterine  gesta- 
tion,  (4)  rotation   of  the  pedicle   of   an   ovarian   or   uterine  tumour, 

(5)  acute  pancreatitis,  (6)  embolism  or  thrombosis  of  the  mesenteric 
vessels,  (7)  various  forms  of  colic — biliary,  renal,  or  intestinal. 

By  the  time  the  symptoms  characteristic  of  interference  with  the 
passage  of  the  intestinal  contents  come  to  predominate,  it  is  usually 
possible  to  exclude  most  of  these  conditions,  and  the  question  left  for 
decision  is  the  cause  of  the  obstruction.  A  consideration  of  all  the 
available  clinical  data  may  enable  a  correct  opinion  to  be  formed  in 
many  cases,  but  in  others  it  is  impossible  to  do  more  than  make  an 
intelligent  guess  as  to  the  cause  of  the  symptoms. 

In  the  infant,  the  most  likely  causes  are  :  (1)  Strangulated  external 
hernia,  (2)  intussusception,  (3)  one  or  other  form  of  retroperitoneal 
hernia,  (4)  congenital  abnormalities  of  the  rectum  or  intestine.  In 
the  child  over  two  years  of  age,  the  possibilities  are:  (1)  Strangu- 
lated external  hernia,  (2)  intussusception,  (3)  strangulation  by 
Meckel's  diverticulum,  (4)  strangulation  by  bands  or  adhesions, 
particularly  if  there  is  a  history  of  tuberculous  peritonitis,  appen- 
dicitis, injury,  or  a  previous  operation;  (5)  retroperitoneal  hernia. 
In  the  adult,  (1)  strangulated  external  hernia,  (2)  volvulus, 
(3)  strangulation  by  bands  or  through  apertures,  (4)  retroperitoneal 
hernia,   (5)    impaction    of    a    gall-stone    or  a    fsecal    concretion,    and 

(6)  pressure  of  tumours  external  to  the  bowel,  are  among  the  primary 
causes  of  acute  obstruction.  It  is  possible  that  a  gradual  narrowing 
of  the  bowel  by  cicatricial  contraction  or  by  the  growth  of  a  malignant 
tumour  may  culminate  in  complete  obstruction  without  any  pre- 
monitory signs  of  stenosis.  In  the  aged,  acute  obstruction  is  usually 
due  to  (1)  sudden  blockage  of  the  narrowed  lumen  in  malignant  disease 
of  the  colon,  (2)  strangulated  external  hernia,  (3)  intussusception, 
or  (4)  fsecal  accumulation. 


ACUTE   OBSTRUCTION 

Diagnosis  of  the  site  of  the  obstruction.  The  Clinical 
distinctions  between  obstruction  in  the  small  intestine  and  in  the 
colon  are  by  no  means  well  marked.  It  may  be  Baid  generally 
thai  the  onsel  of  obstruction  in  the  small  intestine  is  more  acute, 
the  initial  shock  is  greater,  the  pain  more  intense,  and  the  vomiting 
more  copious  and  persistenl  than  when  the  <  * »1< m  is  blocked.  The 
illness  tends  to  run  a  more  rapid  course,  and  the  vomiting  becomes 
sttTcoraceous  sooner. 

Tympanites  is  more  marked  when  the  colon  is  the  seal   of  the 
obstruction,  and  the  dilated  colon  may  be  recognizable     The  patterns 
formed  by  the  distended  bowel,  the  evidence  afforded  by  percussion, 
and  the  situation  of  pain,  are  of  no  constant  value  in  fixing  th< 
of  obstruction. 

Treatment. — Only  when  the  patient's  sufferings  are  extreme, 
and  there  is  good  reason  to  believe  they  may  be  due  to  some  form  of 
colic,  should  opium  be  administered  in  suspected  cases  of  obstruction. 
If  a  single  moderate  dose  of  morphia,  combined  with  atropine,  fails  to 
relieve  the  pain,  no  more  should  be  given  ;  and  if  a  definite  diagnosis 
cannot  be  arrived  at,  arrangements  should  be  made  for  an  immediate 
exploratory  operation.  Meanwhile,  a  turpentine  enema  should  be 
administered,  the  patient  lying  on  his  left  side  with  the  pelvis  raised. 
Nothing  should  be  given  by  the  mouth,  except  occasional  sips  of  warm 
water.     The  use  of  ice  is  to  be  avoided. 

Exploratory  laparotomy. — Before  the  anaesthetic  is  adminis- 
tered the  stomach  should  be  washed  out,  and  if  the  patient  is  unable 
to  empty  the  bladder  a  catheter  should  be  passed.  The  abdomen 
is  opened  below  the  umbilicus  through  the  inner  edge  of  one  or  other 
rectus.  The  incision  should  only  be  large  enough  to  admit  two  or 
three  fingers,  and  the  cavity  should  be  explored  systematically.  The 
caecum  is  first  examined,  and  if  it  is  found  distended,  the  colon  should 
be  traced  down.  If  it  is  empty,  the  obstruction  is  probably  in  the 
small  intestine.  If  a  portion  of  empty  and  contracted  small  intestine 
is  discovered,  it  should  be  traced  upwards  till  it  meets  distended  bowel 
at  the  seat  of  the  lesion.  If  nothing  but  distended  bowel  can  be  found 
it  is  probably  safest  to  secure  the  lowest  loop  that  can  be  reached, 
and  make  a  temporary  artificial  anus  in  it  ;  when  the  bowel  has  been 
emptied  and  the  patient  tided  over  the  dangerous  period,  a  second 
operation  may  be  done  to  discover  and  deal  with  the  cause  of  the 
obstruction.  Every  endeavour  should  be  made  to  prevent  coils  of 
distended  bowel  escaping  from  the  peritoneal  cavity,  as  experience 
shows  that  this  greatly  diminishes  the  patient's  chance  of  recovery, 
even  when  the  cause  of  the  obstruction  is  found  and  removed. 

When  the  cause  of  the  obstruction  is  readily  accessible  and  has 
been  removed,  if  the  bowel  above  is  greatly  distended    it  may  be 


47o  THE   INTESTINES 

emptied,  as  suggested  by  Moynihan,  by  opening  it,  and  passing  a 
straight  glass  tube  over  which  long  stretches  of  the  gut  may  be  pulled. 
The   methods   of  dealing   with   the   various   lesions   which   cause 
obstruction  will  be  referred  to  later. 

2.  Chronic  or  Gradual  Obstruction 

The  freedom  with  which  the  bowel  ccntents  pass  along  the  tube 
may  be  gradually  interfered  with  in  a  variety  of  circumstances.  In 
the  great  majority  of  cases,  the  interference  occurs  in  the  colon,  and 
is  due  to  mechanical  causes,  such  as  the  growth  of  a  tumour  in  the 
bowel  wall  slowly  encroaching  upon  the  lumen  and  narrowing  it,  the 
cicatricial  contraction  of  inflammatory  adhesions  constricting,  kinking, 
or  binding  down  the  bowel,  or  the  pressure  of  an  extrinsic  tumour 
interfering  with  the  peristaltic  action  of  the  gut  or  narrowing  its  lumen. 

In  these  circumstances,  either  there  is  no  disturbance  of  the  vascular 
and  nervous  mechanism  of  the  affected  portion  of  bowel,  or  this  is  a 
factor  of  secondary  importance  and  one  which  only  comes  into  play 
late  in  the  progress  of  the  disease. 

Sooner  or  later,  if  left  alone,  the  interference  with  the  function 
of  the  bowel  becomes  so  great  that  symptoms  of  acute  obstruction 
supervene,  and  in  many  cases  the  crisis  ccm.es  on  suddenly  from  some 
superadded  ccmplication.  This  phase  will  be  considered  separately, 
later  (p.  474),  as  the  clinical  procedure  is  different. 

Pathology  and  morbid  anatomy. — Gradual  obstruction 
is  seen  in  its  most  typical  form  in  malignant  disease  of  the  colon, 
in  which,  without  completely  cccluding  it,  the  growth  gradually  narrows 
the  lumen  of  the  bowel,  either  by  filling  it  up  or  by  cicatricial  con- 
traction, or  by  a  combination  of  these  processes. 

In  those  portions  of  the  bowel — the  small  intestine  and  the  higher 
parts  of  the  colon — in  which  the  faeces  are  usually  fluid,  a  very  con- 
siderable degree  of  narrowing  may  exist  without  appreciable  inter- 
ference with  the  onflow,  and  there  are  no  secondary  structural  changes 
in  the  bowel  of  any  importance,  or  only  a  moderate  degree  of  dilata- 
tion. When  the  narrowing  has  progressed  sufficiently  to  interfere  with 
the  onwaid  passage  of  the  contents,  the  segment  above  the  seat  of  the 
obstruction  becomes  distended,  its  walls,  particularly  the  muscular 
coat,  are  hypertrophied  as  a  result  of  prolonged  and  repeated  attempts 
to  force  the  passage,  and  the  tube  becomes  elongated  and  tortuous. 

Hypertrophy  is  most  marked  in  the  small  intestine,  the  circular 
muscular  fibres  increasing  in  size  and  number  so  that  the  wall  becomes 
thicker  and  firmer  than  normal  (Fig.  431). 

In  the  colon,  dilatation  is  more  prominent  than  hypertrophy, 
and  in  some  conditions  may  reach  extreme  limits,  the  diameter  of 
the  bowel  being  as  much  as  a  foot  (Fig.  402). 


CHRONIC   OBSTRUCTION  17' 

The  mucous  membrane  is  Irritated  by  the  producta  <>f  decom- 
position in  the  stagnating  contents,  and  is  in  a  condition  of  chronic 
catarrh.  Ulceration  Bupervenea  either  as  a  result  of  the  action  "f 
toxins  on  the  inflamed  and  Btretched  mucous  membrane  the  "dis- 
tension ulcers"  of  Kncli. t  or  Erom  the  pressure  of  hard  focal  n 
in  the  lower  colon  Bo-called  stercoral  ulcers  (Fig.  125).  The  ulceration 
may  extend  through  the  bowel  and  lead  to  peritonitis,  or  suppuration 
in  t  he  ret  roperitoneal  tissue. 

So  long  as  the  vascular  mechanism  of  the  bowel  is  intact,  g 
do  not  collect  in  the  dilated  portion,  as  they  are  absorbed  into  the 
circulation,  or  pass  t  hrough  the  narrowed  lumen  into  the  bowel  beyond. 

The  segment  below  the  obstruction  is  pale  and  contracted,  and,  as 
a  rule,  empty,  although  in  some  cases  the  faecal  matter  that  escapes 
past  the  obstruction  collects  in  the  lower  segment  and  may  form  a 
considerable  mass  there,  and  the  bowel  may  even  be  moderately  dis- 
tended with  gas. 

Effects  on  the  mesentery. — As  it  gradually  becomes  more  and 
more  distended,  the  bowel  may  force  its  way  between  the  layers  of 
its  mesentery,  so  that  this  structure  is  appreciably  shortened.  Then 
the  affected  segment  of  bowel  becomes  abnormally  fixed,  and  this 
may  interfere  with  such  operations  as  colostomy  by  rendering  it 
difficult  to  bring  the  pelvic  colon  to  the  surface.  If  the  stretching 
process  continues,  the  peritoneum  covering  the  bowel  may  split  in 
the  long  axis  of  the  gut — "' striation  of  the  mesentery."' 

Clinical  features. — The  symptoms  of  chronic  obstruction 
come  on  insidiously  and,  from  the  way  in  which  they  are  produced, 
the  progress  of  the  malady  is  often  irregular  and  intermittent.  There 
are  periods,  sometimes  lasting  for  days  or  even  weeks,  during  which 
the  patient  has  little  difficulty  with  the  bowels,  followed  by  others 
in  which  a  satisfactory  evacuation  is  only  obtained  by  talcing  strong 
purgatives  or  with  the  aid  of  enema ta. 

The  early  symptoms — a  feeling  of  discomfort  or  a  moderate  degree 
of  pain  and  occasional  attacks  of  vomiting,  particularly  after  taking 
food,  and  a  more  or  less  constant  feeling  of  uneasiness  in  the  abdomen 
— are  usually  attributed  by  the  patient  to  dyspepsia.  There  is  great 
complaint  of  flatulence,  which  the  patient  has  difficulty  in  getting 
to  pass  downwards.  Either  these  symptoms  are  neglected,  or  treat- 
ment is  directed  towards  the  stomach.  Morning  diarrhoea — that  is, 
passage  of  a  fluid  stool  immediately  on  getting  up — is  a  common  and 
characteristic  symptom  of  cancerous  obstruction  of  the  lower  colon. 

As  time  goes  on,  the  patient  finds  a  difficulty  in  securing  a  regular 
and  satisfactory  evacuation  of  the  bowels,  and  succeeds  in  doing  so 
only  by  taking  purgatives,  the  dose  and  frequency  of  which  require 
to  be  increased  without,  however,  being  followed  by  a  corresponding 


472 


THE   INTESTINES 


result.  Eventually,  the  medicine  has  no  effect  on  the  bowels,  and 
onlv  induces  attacks  of  severe  griping  pain,  which  may  be  accom- 
panied by  vomiting,  and  are  often  relieved  by  making  pr» 
on  the  abdomen  or  by  rubbing  it.  Sometimes  the  pain  is  increased 
by  pressure.  When  the  obstruction  is  in  the  colon,  the  patient  is 
often  able  to  locate  it  very  accurately  by  the  point  at  which  the 
pain  reaches  the  maximum  during  a  spasm  of  colic. 

There  is  often  a  history 
of  attacks  of  diarrhoea  in 
which  a  small  quantity  of 
fsecal  matter  mixed  with  a 
considerable  amount  of  mucus 
is  passed,  and  these  attacks 
are  attended  with  great  strain- 
ing and  are  not  followed  by 
any  feeling  of  relief.  They 
are  due  to  catarrhal  inflam- 
mation of  the  mucous  mem- 
brane set  up  by  the  fsecal 
masses  retained  above  the 
seat  of  obstruction.  A-  a 
rule,  these  attacks  of  spurious 
''diarrhoea"  alternate  with 
periods  of  marked  constipa- 
tion— a  combination  of  cir- 
cumstances which  is  very 
characteristic  of  chronic  ob- 
struction of  the  colon. 

Gradually  the  bowel  above 
the    obstruction   is    distended 
and  hypertrophied,  the  abdo- 
men becomes  more  prominent, 
and   visible   peristaltic    waves 
mav  be  observed  to  pass  along  the  gut  from  time  to  time.     Visible 
peristalsis  is  perhaps   the  most  certain  clinical  indication  of  chronic 
obstruction. 

On  rectal  examination,  it  is  frequently  found  that,  after  passing 
through  the  anal  canal,  the  finger  enters  a  wide  open  space,  the  walls 
of  which  it  is  difficult  to  reach.  When  touched,  the  mucous  membrane 
is  smooth,  the  rugae  having  disappeared,  and  the  rectum  appears  to 
be  unduly  fixed.  This  condition,  known  as  "  ballooning  of  the 
rectum."  is  due  to  paralysis  of  the  gut,  and  is  most  frequently  met 
with  in  cases  of  stenosis  of  the  descending  and  pelvic  portions  of  the 
colon. 


Fig.  406. — Dilated  coils  of  small  intes- 
tine forming  "  ladder  "  or  "  organ- 
pipe  pattern,"  from  a  case  of 
chronic  tuberculous  peritonitis  with 
adhesions. 

(From   Treves' s  "  Intestinal  Obstruction.") 


CIIKo.MC   OBSTRUCTION 


473 


When  tin-  small  intestine  is  chronically  distended,  the  contracting 
coils  stand  <mt  as  a  Beries  oil  tubular  prominences  running  aoro 
abdomen,  suggesting  the  appearance  oi  the  rungs  of  a  ladder, 
Bel  "f  organ   pipes — "ladder"  or  "organ-pipe  pattern"   (Kg 
When    the    distension    affects    principally    the    large    intestine,    the 
different   parts  of  the  colon  may  be  recognized  to  be  distended,  bnl 
they  Beldom  exhibit  peristaltic  waves  bo  distinctly  as  does  the  small 
intestine  (Kg.   I<>7). 

Thes.>  waves  of  peri- 
Btalsia  are  accompanied  by 
attacks  of  colicky  pain,  and 
often  by  Loud  rumbling  or 
gurgling  sounds,  spoken  of 
Btenosis  noises "  or 
"  borborvgnii,"  and  on  palp- 
ation the  contracting  loop 
of  bowel  is  felt  to  become 
firm  and  rigid. 

Gradually  the  symptoms 
become  more  severe  and 
continuous.  The  digestion 
is  seriously  disturbed,  the 
tongue  and  mouth  become 
coated,  the  breath  has  an 
offensive  frecal  odour,  and 
the  patient  is  poisoned  by 
toxins  absorbed  from  the 
stagnant  and  decomposing 
contents  of  the  gut.  Symp- 
toms of  collapse  are  pre- 
sent   only  when  there    is  a 

marked  degree  of  toxa?mia.  Finally,  death  results,  either  from  the 
toxaemia  and  exhaustion  induced  by  it,  or  from  the  sudden  occurrence 
of  perforation  and  peritonitis. 

Diagnosis. — There  is  never  any  difficulty  in  recognizing  that 
the  patient  is  suffering  from  chronic  obstruction,  but  it  may  not  be 
easy  to  form  an  opinion  as  to  the  cause.  A  careful  analysis  of  all  the 
clinical  features,  including  the  history,  usually  throws  some  light  on 
the  question.  The  following  are  among  the  possible  causes  :  In  the 
child  :  (1)  Adhesions  associated  with  tuberculous  or  other  forms  of 
peritonitis,  (2)  tuberculous  disease  of  the  bowel  or  mesenteric  glands 
followed  by  cicatricial  stenosis,  (3)  chronic  forms  of  intussuscep- 
tion, (4)  Hirschsprung's  disease.  In  the  adult  :  (1)  Peritoneal 
adhesions,    (2)   cicatricial   strictures,    (3)   malignant    disease,    (4)   ileo- 


Fig.  407. — Dilatation  of  pelvic  colon 
above  a  stricture. 

(From  Treves' s  "  Intestinal  Obstruction."} 


474  THE    INTESTINES 

csecal  tuberculosis  ;  (5)  fibromatosis  of  the  colon,  (6)  actinomycosis, 
(7)  primary  chronic  intussusception,  (8)  pressure  of  extrinsic  tumours. 
In  the  aged  :  (1)  Malignant  disease,  (2)  chronic  intussusception, 
(3)  faecal  concretions,  (4)  faecal  accumulation. 

The  treatment  of  chronic  obstruction  depends  upon  the  lesion 
causing  it,  and  will  be  described  later. 

3.  Chronic  Obstruction  terminating  Acutely 

One  of  the  most  common  terminations  of  gradually  increasing 
stenosis  of  the  bowel  is  the  onset  of  symptoms  of  acute  obstruction 
brought  about  by  sudden  occlusion  of  the  narrowed  lumen.  This  may 
be  due  to  a  hard  fcecal  mass,  a  gall-stone,  or  a  foreign  body  blocking 
the  aperture,  or  to  congestion  of  the  mucous  membrane  following 
the  taking  of  a  strong  purgative.  In  other  cases,  it  results  from 
kinking  or  torsion  of  the  affected  segment  brought  about  by  rapid 
distension  with  gases,  or  by  a  sudden  change  of  position.  In  advanced 
cases,  the  bowel  may  be  exhausted  by  its  attempts  to  overcome  the 
obstruction,  and  become  relaxed  or  even  paralysed. 

The  changes  in  the  bowel  present  a  combination  due  to  the 
gradual  obstruction  with  the  superadded  effects  of  complete  occlu- 
sion in  the  form  of  increased  vascular  engorgement  and  gaseous 
distension. 

Unless  relieved  by  operation,  the  condition  usually  terminates 
fatally,  either  by  exhaustion  induced  by  pain  and  vomiting,  and  inter- 
ference with  the  action  of  the  lungs  and  heart  due  to  the  distended 
bowel  pressing  upon  the  diaphragm,  or  by  peritonitis  set  up  by  organisms 
passing  through  the  wall  of  the  gut  or  from  perforation.     ^ 

KETKOPERITONEAL   HERNIA 

In  the  early  embryo,  the  intestinal  canal  consists  of  an  almost 
straight  tube  attached  to  the  middle  line  of  the  body  by  a  fold  of 
peritoneum — the  primitive  mesentery.  As  the  different  segments  of 
the  alimentary  canal  and  the  associated  glands  are  differentiated 
and  assume  the  dimensions  and  position  of  the  fully  developed  organs, 
this  mesentery  undergoes  a  corresponding  series  of  changes,  certain 
parts  becoming  elongated,  while  others  become  shortened  and  fixed. 
Without  going  into  details,  it  may  be  said  that,  as  a  result  of  these 
and  other  changes,  various  peritoneal  folds  with  intervening  fossse 
are  developed  on  the  posterior  abdominal  wall,  particularly  in  relation 
to  the  flexures  of  the  intestinal  canal.  The  surgical  significance  of 
these  fossse  lies  in  the  fact  that  they  may  assume  such  dimensions 
as  to  form  potential  sacs  into  which  a  loop  of  bowel  may  pass  and 
become  strangulated. 

The  situations  in  which  such   retroperitoneal  hernias  may  occur 


DUODENAL    HERNIA  475 

are  (1)  a1  the  termination  of  the  duodenum;  (2)  in  the  vicinity  of 
the  caecum  and  appendix;  (•">)  in  the  mesentery  of  the  pelvic  colon. 
Hernia  into  the  foramen  of  Window,  and  diaphragmatic  liernia, 
although  not  Btrictly  retroperitoneal,  are  Eor  convenience  included 
in  t  his  sec)  ion. 

Duodenal  Hernia 

Numerous  Eossse  bave  been  described  in  relation  wit  h  the  duodeno- 
jejunal junction.  The  most  importanl  Eor  our  presenl  purpi 
the  paraduodenal  fossa,  which  is  situated  on  the  left  side  of  the  ascend- 
ing portion  of  the  duodenum.  Its  left  border  is  formed  by  I  he  inferior 
mesenteric  vein  and  its  righl  by  the  duodeno-jejunal  flexure.  Its 
orifice  looks  downwards  and  to  the  right,  its  blind  extremity  being 
directed  upwards  and  to  the  left.  Into  this  fossa,  the  left  form  of 
duodenal  hernia  passes,  and  as  it  increases  in  size  i)  extends  down 
behind  the  transverse  and  descending  colon. 

The  nexl  most  important  is  the  mesenterico-parietal  fossa.  This 
lies  in  the  mesentery  of  the  jejunum,  immediately  below  the  duodenum 
and  behind  the  superior  mesenteric  artery,  which  forms  its  anterior 
boundary.  Its  orifice  looks  to  the  left,  and  its  base  downwards  and 
to  the  right,  and  into  it  the  right  form  of  duodenal  hernia  p 
extending  down  behind  the  transverse  and  ascending  colon. 

Clinical  features. — Duodenal  hernia  has  been  met  with  at 
all  ages  ;  some  of  the  recorded  cases  have  occurred  in  infants.  Its 
presence  is  never  suspected  unless  strangulation  lias  occurred,  and 
even  then,  in  the  vast  majority  of  cases,  the  cause  of  the  obstruction 
has  only  been  discovered  on  opening  the  abdomen. 

The  symptoms  that  may  suggest  the  presence  of  a  duodenal  hernia 
are  long-continued  dyspepsia  and  irregularity  of  the  bowels  with 
colicky  pains,  and  the  presence  of  a  circumscribed  globular  swelling, 
resembling  a  movable  cyst,  except  that  it  is  resonant  on  percussion 
and  yields  intestinal  sounds  on  auscultation.  Owing  to  the  com- 
pression of  the  inferior  mesenteric  vein  at  the  neck  of  the  fossa,  the 
patient  usually  suffers  from  piles,  which  bleed  freely. 

When  strangulation  ensues,  all  the  symptoms  of  acute  obstruction 
are  present,  and  as  it  is  usually  the  first  part  of  the  jejunum  that  is 
implicated,  profound  shock  and  persistent  vomiting  are  prominent 
symptoms. 

Treatment. — When,  on  opening  the  abdomen  in  a  case  of 
obstruction,  the  cause  is  found  to  be  a  strangulated  duodenal  hernia, 
the  bowel  must  be  withdrawn  from  the  fossa  without  dividing  the 
neck  of  the  sac,  in  which  runs  the  inferior  mesenteric  vein  or  the 
superior  mesenteric  artery.  An  attempt  should  be  made  to  close  the 
opening  into  the  fossa  by  suturing  its  margins,  and  so  prevent  re- 
currence of  the  hernia. 


476  THE    INTESTINES 

Pericecal  Hernia 

Several  fossse  are  present  in  the  vicinity  of  the  ileo-csecal  junction, 
the  most  important  from  the  surgical  point  of  view  being  the  ileo- 
appendicular,  which  lies  between  the  ileo-appenclicular  or  "  bloodless  " 
fold  of  Treves  and  the  mesentery  of  the  vermiform  appendix  ;  and 
the  retrocolic,  lying  behind  the  caecum  and  the  lower  part  of  the 
ascending  colon. 

The  existence  of  a  hernia  into  one  or  other  of  these  pouches  is 
never  recognized  unless  strangulation  occurs,  and  then  the  symptoms 
are  those  of  acute  obstruction.  Usually,  the  hernia  can  readily  be 
withdrawn  from  the  sac,  and  the  obliteration  of  the  pouch  is  facilitated 
by  removal  of  the  appendix. 

Hernia  of  the  vermiform  appendix  alone  into  a  fossa  is  not  uncom- 
mon, and,  if  the  appendix  becomes  strangulated,  symptoms  of  acute 
appendicitis  develop. 

Intersigmoid  Hernia 

This  extremely  rare  form  of  hernia  passes  into  the  intersigmoid 
fossa,  which  is  formed  by  the  layers  of  the  mesentery  of  the  pelvic 
colon  over  the  bifurcation  of  the  common  iliac  artery  and  near  the 
inner  margin  of  the  psoas  muscle.  The  sigmoid  vessels  run  in  the 
fold  of  peritoneum  which  forms  its  anterior  margin. 

Hernia  into  the  Foramen  of  Winslow 

Hernia  through  the  foramen  of  Winslow  is  very  rare,  and  is  only 
possible  when  the  foramen  is  exceptionally  large,  owing  to  some  con- 
genital abnormality. 

When  strangulation  occurs,  the  usual  signs  of  acute  obstruction 
are  present,  the  pain  being  intense  and  situated  in  the  epigastrium, 
and  a  swelling,  which  is  dull  on  light  percussion  but  gives  a  resonant 
note  on  deeper  percussion,  can  usually  be  made  out.  It  is  a  curious 
fact  that  there  is  no  evidence  of  pressure  on  the  hepatic  vessels  or 
bile-duct,  which  run  in  the  margin  of  the  foramen. 

The  treatment  consists  in  opening  the  abdomen  and  with- 
drawing the  strangulated  coil.  As  the  structures  in  the  margins  of 
the  foramen  forbid  division  of  the  constricting  agent,  if  reduction 
cannot  be  effected  by  traction  the  lesser  sac  of  the  peritoneum  must  be 
opened  through  the  gastro-hepatic  or  gastro-colic  omentum,  and  the 
distended  bowel  withdrawn  and  emptied.  After  the  opening  in  the 
bowel  is  sutured,  it  is  returned  to  the  lesser  sac  and  withdrawn  through 
the  foramen. 

Diaphragmatic  Hernia 

This  term  is  applied  to  any  protrusion  of  the  abdominal  contents 
through  the  diaphragm,  although  in  nearly  90  per  cent,  of  cases  there 


DIAPHRAGMATIC    HERNIA  177 

is  no  peritoneal  sue,  and  the  condition  is  rather  one  of  prolapse  than 
of  true  hernia. 

Morbid  anatomy.- -The  protrusion  may  lake  place  (1)  through 
one  or  other  of  the  natural  openings  in  the  diaphragm,  particularly 
that    for  the  oesophagus;    (2)    through    a    congenita]    deficiency    in 

the  muscle;  (."»)  through  a  tear  produced  by  indired  violence  or 
muscular  effort  ;   or  (4)  through  a  direct  wound  of  the  muscle. 

The  condition  is  usually  met  with  on  the  left  side,  where  the 
diaphragm  lacks  the  support  of  the  liver.  The  size  of  the  opening 
varies  from  a  mere  slit  in  the  tendinous  portion  of  the  diaphragm 
to  a  complete  absence  of  one  half  of  the  muscle. 

As  a  rule  the  viscera  are  prolapsed  into  the  left  pleural  cavity, 
and  the  organs  most  frequently  implicated  are  the  stomach,  the  colon, 
and  the  small  intestine.  The  liver,  pancreas,  spleen,  and  left  kidney 
have  also  been  found  in  such  hernias. 

The  majority  of  cases  of  congenital  diaphragmatic  hernia  have 
been  met  with  on  post-mortem  examination  of  still-born  children,  or 
of  infants  who  have  only  survived  a  few  days.  Others  have  been  found 
at  the  autopsy  of  adults  who  have  never  manifested  any  clinical  signs 
of  such  a  condition.  In  cases  of  traumatic  origin,  signs  may  develop 
soon  after  the  injury,  or  not  till  long  after. 

Clinical  features. — The  condition  has  very  seldom  been 
accurately  diagnosed  during  life.  As  the  stomach  is  almost  always 
present  in  the  hernia,  gastric  discomfort  constitutes  the  chief  com- 
plaint, and  the  patient  may  be  conscious  that  the  food  lodges  in  the 
region  of  the  chest,  where  it  produces  a  fixed  pain. 

On  examination,  an  unnatural  depression  in  the  epigastric  and 
left  hypochondriac  regions  may  be  noted,  with  a  corresponding  fullness 
in  the  lower  thoracic  region.  The  thoracic  signs  are  similar  to  those 
of  pneumothorax,  but  are  detectable  chiefly  in  the  lower  part  of  the 
chest,  and  distinct  intestinal  gurgling  may  sometimes  be  heard  on 
auscultation.  The  heart  may  be  displaced  and  its  action  interfered 
with,  causing  palpitation,  attacks  of  dyspncea  and  oppression  in  the 
chest,  with  inability  to  lie  on  the  left  side. 

These  symptoms  are  influenced  by  the  taking  of  food  or  fluid  and 
sometimes  by  exertion,  and  the  rapid  variations  in  the  physical  signs 
help  to  differentiate  this  condition  from  pneumothorax. 

Information  may  be  obtained  by  taking  an  X-ray  photograph 
after  administering  a  bismuth  meal,  or  following  an  injection  of  bismuth 
emulsion  into  the  colon. 

When  the  hernia  is  suddenly  produced,  there  is  intense  dyspncea 
and  cyanosis,  with  severe  prsecordial  pain  and  oppression,  and  the 
condition  may  rapidly  prove  fatal  from  shock  or  from  compression 
of  the  lung. 


478  THE   INTESTINES 

Strangulation  is  associated  with  all  the  signs  of  acute  obstruction. 
It  may  be  determined  in  an  old-standing  hernia  by  some  sudden  and 
violent  muscular  effort,  or  by  a  crush  of  the  body.  In  traumatic 
cases,  the  bowel  may  become  strangulated  at  the » moment  it  passes 
through  the  rent  in  the  diaphragm. 

Treatment. — In  recent  traumatic  cases,  an  attempt  should 
always  be  made  to  replace  the  prolapsed  viscera  in  the  peritoneal 
cavity.  The  rent  in  the  diaphragm  must  be  closed  by  suture,  and 
to  effect  this  it  may  be  necessary  to  enlarge  the  wound  and  even  to 
resect  portions  of  one  or  more  ribs. 

When  strangulation  has  occurred  and  the  hernia  is  discovered  on 
opening  the  abdomen,  before  any  attempt  is  made  to  reduce  it  the 
pleural  cavity  should  be  opened  by  a  U-  or  T-shaped  incision,  with 
resection  of  ribs,  to  avoid  the  risk  of  pulling  a  gangrenous  or  per- 
forated loop  of  bowel  into  the  peritoneal  cavity,  to  enable  the  pleural 
cavity  to  be  purified  and  drained,  and  to  facilitate  the  subsequent 
closure  of  the  opening  in  the  diaphragm. 

To  avoid  the  risks  of  pneumothorax  incident  to  free  opening  of 
the  pleural  cavity,  such  operations  should,  if  possible,  be  done  under 
altered  atmospheric  pressure. 

PERITONEAL    ADHESIONS 

All  varieties  of  inflammation  of  the  peritoneum  are  liable  to  be 
followed  by  the  formation  of  adhesions  between  adjacent  serous  surfaces. 
In  certain  circumstances — for  example,  after  surgical  operations  on 
the  bowel,  as  a  sequel  to  drainage  of  the  peritoneal  cavity  in  cases  of 
gastric  or  intestinal  ulcers,  cholecystitis,  or  disease  of  the  mesenteric 
glands — the  adhesions  are  confined  to  the  vicinity  of  the  irritant,  and 
may  only  persist  as  long  as  the  irritation  lasts,  serving  a  protective 
purpose  and  being  absorbed  when  they  are  no  longer  required.  On 
the  other  hand,  as  a  sequel  to  such  conditions  as  generalized  septic 
or  tuberculous  peritonitis,  the  adhesions  may  involve  the  whole  of 
the  peritoneal  membrane,  matting  the  intestines  into  an  inextricable 
mass,  and  fixing  the  viscera  to  one  another  and  to  the  parietal  peri- 
toneum. 

Between  these  extremes  all  degrees  are  met  with,  and  the  adhesions 
may  take  the  form  of  broad  thin  sheets  of  fibrous  tissue  stretching 
between  adjacent  coils  of  bowel  (Fig.  408),  or  narrow  strands  fixing 
one  short  loop  to  another,  or  they  may  be  moulded  into  long  cord- 
like bands  passing  from  one  part  of  the  abdominal  cavity  to  another. 

The  effect  of  adhesions  on  the  function  of  the  bowel  bears  no  direct 
relation  to  their  extent  or  disposition,  and  it  is  remarkable  how  little 
disturbance  may  result  even  when  the  whole  intestine  is  matted  into 
what  appears  to  be  a  solid  mass.     When  adhesions  do  give  rise  to 


PERITONEAL   ADHESIONS 


479 


symptoms,  these  may  take  the  form  of  repeated  at1  colicky 

pain  with  vomiting,  a  moderately  acute  obstruction,  or  a  gradually 
increasing  interference  with  the  of  the  intestinal  contents. 

Obstruction    due    to    peritoneal  adhesions.     Tin-    more 
acute    form   of  obstruction    is    usually    due    to    kinking,  bendii 
of   a    short    Begmenl  of    bowel,  which  is  suddenly    >\- 
upon  by  an  adhesion  attached  to  its  border  bo  that  the  lumen  is 
occluded.     The  traction  may  be  due  to  distension  of  the  coil  b 
or  to   some   change    in   position.     As 
this  mechanism  dues  not  involve  any 
serious    interference    with    the    blood 
supply  "f  the  affected  coil,  the  symp- 
toms are    less    acute    than   when    the 
bowel    is    strangulated,    for   example, 
by  a  band.     The  cause  of  this  form  of 
obstruction  is  seldom  diagnosed  before 
the  abdomen  is  opened,  but  the  his- 
tory  of  previous  peritonitis  or  trauma 
should  suggest  the  possibility  of  peri- 
toneal adhesions. 

Limited  adhesions  may  be  separ- 
ated and  steps  taken  to  prevent  their 
re-formation  by  smearing  the  raw  sur- 
faces with  sterilized  vaseline  oil. 

The  more  gradual  form  of  obstruc- 
tion is  due  to  fixation  of  a  loop  of 
bowel ;  to  localized  constriction  by  ad- 
hesions which  encircle  a  segment ;  to 
cicatricial  contraction  of  the  mesentery  ; 
or  to  widespread  adhesions  matting  a 
number  of  coils  into  a  confused  mass, 
as  is  frequently  seen  in  cases  of  tu- 
berculous peritonitis,  or  of  disease  of 
the  mesenteric  glands.  The  chronic- 
symptoms — vague  abdominal  discom- 
fort, colicky  pains  with  occasional  attacks  of  vomiting,  gradually 
increasing  difficulty  in  securing  a  regular  action  of  the  bowels,  and 
progressive  distension — often  culminate  in  acute  obstruction. 

This  form  of  obstruction  may  usually  be  diagnosed  from  the  hisl 
of  previous  disease  in  the  glands  or  peritoneum,  from  the  gradual 
progress  of  the  symptoms,  and  in  many  cases  from  the  detection  of  a 
localized  swelling  in  the  abdomen  or  on  rectal  examination. 

If  the  adhesions  cannot  be  separated  and  resection  of  the  afT 
segments  is  impracticable,  an  anastomosis  should  be  established  between 


Fig.  408.  —  Illustrating  the 
formation  of  a  fibrous 
band  between  two  coils  of 
small    intestine. 

(Museum.   Royal  College  of  Surgeons, 
Edinburgh. ) 


480 


THE    INTESTINES 


the  bowel  above  and  below  the  obstruction.  If  this  is  not  possible  at 
the  time,  a  temporary  opening  must  be  made  in  the  bowel  above  the 
obstruction,  and  a  more  radical  operation  performed  when  the  patient 
is  in  a  better  condition  to  stand  it.  The  results  of  these  operations 
have  been  very  satisfactory,  especially  in  cases  due  to  tuberculosis. 

STRANGULATION  BY  BANDS  AND  THROUGH 
ABNORMAL  APERTURES 

Strangulation   by  bands.— This  is  a  common  cause  of  acute 
obstruction.     The  constricting  agent  may  be  a  solitary  fibrous  band 


Fig.  409. — Obstruction  of  loop  of  small  intestine  by  a  band. 
( Semi -diagrammatic.) 

passing  across  the  peritoneal  cavity,  a  portion  of  the  great  omentum 
that  has  formed  abnormal  attachments,  a  Meckel's  diverticulum,  or 
some  misplaced  and  abnormally  attached  anatomical  structure,  such 
as  the  vermiform  appendix  or  the  Fallopian  tube. 

1.  Solitary  peritoneal  bands  result  from  the  moulding  and  stretching 
of  plastic  exudate  between  two  inflamed  peritoneal  surfaces.  They 
are,  therefore,  most  commonly  found  in  the  vicinity  of  the  vermiform 
appendix  (Fig.  411)  and  female  pelvic  organs,  near  hernial  apertures, 


si  K  Wia  l  ATION    HV    II  WDS 


or  in  relation  with  localized  f"<  i  of  tuberculoma  either  in  the  bowel  or 
the  mesenteric  glands.     Not  infrequently   i  band  forms  it  the 
a  previous  operation. 

\  i  rule,  one  end  of  the  band  is  attached  to  the  mesentery  and 
tli<-  othei  i"  the  parietal  peritoneum,  to  another  pari  of  the  mesent- 
i]  t<>  ..in'  of  tin'  viscera  (Fig.  llh.  < » .  < : i - i - » 1 1 ; 1 11  \  one  extremity 
becomes  separated, 
ami  floats  Eree  among 
tin-  viscera. 

B  ads  vary  in 
length  from  :i  frac- 
tion of  an  inch  to 
1  iiK  lies,  and 
in  thickness  from,  a 
mere  thread  to  a 
cord  as  thick  as  the 
ringer.  As  a  rule, 
they  are  round  and 
cord-like,  but  some- 
they  are  flat- 
tened like  a  ribbon. 

_'.  Omental  bands. 
— The  free  edge  of 
the  great  omentum 
infrequently 
forms  attachments 
with  some  part  that 
has  been  the  seat  of 
inflammation,  such 
as  the  region  of  the 
vermiform  appendix, 
the  Fallopian  tube, 
tuberculous  mesen- 
teric   glands,    or    a 

loop  of  intestine  which  has  been  injured  or  is  the  seat  of  ulceration  ; 
and  in  course  of  time  the  adherent  portion  becomes  so  stretched  and 
moulded  as  to  constitute  a  band.  Bands  formed  in  this  way  are 
usually  broader  and  stronger  than  peritoneal  bands,  and  the  fact 
that  one  end  is  always  attached  to  the  transverse  colon,  which  is 
movable  and  yielding,  explains  why  strangulation  by  an  omental 
band  is   generally  less  acute  than  that   caused  by  a  fibrous  cord. 

There  is  often  more  than  one  omental  band — a  fact  which  must 
be  borne  in  mind  in  cases  of  obstruction,  lest  the  whole  of  the  con- 
stricting agent  be  not  divided. 
- 


Fig.  410. — Obstruction  of  small  intestine  by  a 
band,  with  volvulus  of  the  strangulated  loop. 
( Semi  -diagrammatic.) 


482 


THE   INTESTINES 


3.  A  Meckel's  diverticulum  may  cause  obstruction  by  acting  as  a 
Land  (Fig.  401,  p.  445). 

4.  Bands  formed  by  anatomical  structures  abnormally  attaclted. — 
Among  anatomical  structures  which  may  act  as  bands  and  so 
cause  obstruction  may  be  mentioned  the  vermiform  appendix. 
which  may  become  attached  to  the  right  ovary,  to  the  uterus,  to 
an  adjacent    portion    of    mesentery    (Fig.  412),  or    to  the    anterior 

ibdominal  wall. 
The  Falloj 
tube  (Plate  93),  or 
even  an  enlarged 
appendix  epiploica, 
may  act  in  a  similar 
manuer. 

I  have  operated 
on  one  case  in  which 
the  pedicle  of  a  fibroid 
of  the  uterus  en- 
snared a  coil  of  small 
intestine  and  caused 
obstruction,  and  on 
another  in  which  the 
pedicle  of  an  ovarian 
cyst  was  the  cause 
of  obstruction. 

Strangulation 
through  abnor- 
mal apertures. — 
In  the  majority  of 
of  obstruction 
due  to  this  cause, 
the  small  intestine  is 
prolapsed  through  an  abnormal  aperture  in  the  mesentery  of  the  lower 
ileum.  Such  apertures  may  be  congenital,  but  are  usually  the  result 
of  a  previous  injury,  the  mesentery  having  been  torn  by  a  kick  or 
crush  of  the  abdomen,  or  divided  in  the  course  of  an  operation  and 
not  united  again.  In  course  of  time  the  edges  of  the  rent  become 
smooth,  rounded,  and  unyielding,  and  a  ring  or  slit  is  formed  into 
which  a  knuckle  of  bowel  may  at  any  time  slip.  Similar  apertures 
mav  be  met  with  in  the  great  omentum,  and  less  frequently  in  the 
mesentery  of  the  transverse  and  descending  colon.  Slits  are  sometimes 
formed  by  stretched  adhesions  resulting  from  peritonitis,  particularly 
in  relation  to  the  female  pelvic  organs. 

Clinical  features. — The   symptoms   are   usually  those  of  the 


Fig.  411. — Strangulation  of  small  intestine  in  a 
child  by  a  cord-like  band  stretching  between 
the  vermiform  appendix  and  a  coil  of  small 
intestine. 

{Author's  case.) 


SIR  AMilLA  [  ION    \\\    BANDS 


tttosl  acute  forma  oi  intestina]  obstruction  (p.  165).  Examination 
of  the  abdomen  seldom  reveals  any  localizi?  ml  rectal  examina- 
tion is  likewise  negative.  It  is  not  uncommon,  however",  fox  a  con- 
siderable quantity  of  1>1 1  to  be  passed  by  the  rectum,  and  in  children 

this  may  surest   the  possibility  of  intussusception.     A  bistory  that 


Fig.  412. — Portion  of  small  intestine  strangulated 
by  vermiform  appendix  acting  as  a  band. 

{Anai   'itical    Museum,   University  of  Edinburgh^ 

the  patient    has  previously  suffered  from  some  form  of  peritonitis, 
especially  tuberculous,  should  suggest  the  presence  of  a  band. 

Treatment. — In  the  great  majority  of  cases,  it  is  impossible 
to  arrive  at  a  positive  diagnosis  as  to  the  cause  of  the  obstruction 
before  the  abdomen  is  opened.  The  escape  of  blood-stained  fluid  on 
opening  the  peritoneal  cavity  is  strongly  suggestive  of  the  presence 
of  a  band  or  of  volvulus.  Any  loop  of  contracted  intestine  that  can 
be  found  should  be  traced  upwards  until  the  seat  of  obstruction  is 
reached.  If  a  band  is  discovered,  it  should,  if  possible,  be  divided 
between  forceps  and  the  secured   ends   removed. 


4§4 


THE   INTESTINES 


When  the  bowel  is  prolapsed  through  an  aperture,  it  is  usually- 
necessary  to  divide  the  constricting  ring  before  it  can  be  released, 
and  in  doing  so  care  must  be  taken  not  to  interfere  unduly  with  the 
vessels  of  the  mesentery  lest  the  blood  supply  to  the  intestine  be 
diminished.  The  opening  should  be  closed  by  sutures  to  prevent 
recurrence  of  the  protrusion.     If  the  strangulated  loop  is  gangrenous, 


Fig.  413. — Diagram  of  intussusception. 

{Modified from  R.  C.   Coffey.) 

t  should  be  resected  ;  but  if  the  patient  cannot  stand  this  at  the 
time,  it  must  be  brought  to  the  surface,  opened,  and  drained,  the 
resection  being  postponed  until  the  conditions  are  more  favourable. 

INTUSSUSCEPTION 

Intussusception  may  be  defined  as  the  invagination  of  one  part 
of  the  intestine  into  the  lumen  of  the  immediately  adjoining  part. 
In  the  great  majority  of  cases  it  is  the  upper  segment  of  bowel  that 
passes  into  the  lower. 


IMTSSl   s<    I   I'l  l()\ 


The  condition  is  most  frequently  met  with  in  young  children,  and 
in  them  gives  rifle  to  one  form  of  acute  obstruction.  When  it  occurs 
,i-  a  primary  affection  in  the  adult,  the  Bymptoms  are  usually  those 
oi  a  gradual  or  intermittenl  obstruction,  which,  however,  may  cul- 
minate in  an  acute  and  complete  attack. 

A  typical  intussusception  forms  a  firm,  rigid,  sausage-like  Bwelling, 
which,  on  account  of  the  traction  on  the  mesentery,  usually  assumes 
a  semilunar  or  horseshoe  shape.  It  is  composed  oi  three  concentrically 
arranged  tubes  of  bowel,  which  are  differentiated  from  without  inwards, 
as  follows:  (1)  the  receiving  tube  or  sheath  ;  (2)  the  returning  tube  : 
and  (3)  the  entering  lube.  The  entering  and  returning  tubes  together 
form  the  intussusceptum,  and  the  receiving  tube  is  the  intussua 
The  most  advanced  part  of  the 
intussusceptum.  where  the  en- 
tering and  returning  layers  join, 
is  known  as  the  apex,  and  is 
usually  the  starting-point  of  the 
invagination ;  and  the  part  at 
which  the  returning  and  receivirig 
layers  are  continuous,  and  where 
the  mesentery  enters,  is  spoken 
of  as  the  neck.  In  the  space  be- 
tween the  entering  and  return- 
ing layers,  on  the  concave  side  of 
the  intussusception,  the  mesen- 
tery is  tightly  packed  (Fig.  413). 

In  vertical  section,  the  mass 
consists  of  six  layers,  three  on 
each   side  of  the  central  canal  ; 

and  on  transverse  section,  of  three  concentric  rings,  so  arranged 
that  mucous  surfaces  are  in  contact  with  mucous  surfaces,  and 
serous  with  serous  (Fig.  -114). 

Multiple  intussusceptions. — If  the  sheath  is  abnormally 
loose  it  may  become  folded  on  itself,  forming  a  double  intussusception 
(Fig.  416).     In  rare  cases  it  is  twice  folded — triple  intussuscept 

A<  eording  to  the  segment  of  bowel  implicated,  three  types  of  intus- 
susception are  recognized  :  the  entero-colic,  in  which  the  small  intestine 
is  invaginated  into  the  colon  ;  the  colic,  in  which  the  one  part  of  the 
colon  passes  into  the  adjacent  part  ;  and  the  enteric,  in  which  one 
part  of  the  small  intestine  is  invaginated  into  another  part. 

Acute  Intussusception  in  the  Child 
A-  the  great  majority  of  cases  of  intussusception  occur  in  children 
and  involve   the   ileo-caxal   region,   giving  rise   to   a    form  of  acute 


Fig. 


414. — Cross-section    of 
intussusception. 


4'' 


THE   INTESTINES 


Fig.  415. — Single  intussusception. 


obstruction,  it  is  convenient 
for  clinical  purposes  to  de- 
scribe the  condition  in  terms 
of  this  variety. 

Three  different  forms  are 
met  with :  (1)  The  ileo-coecal. 
in  which  the  ileo-csecal  valve 
forms  the  apex  of  the  in- 
tussusception—  this  is  the 
commonest  form ;  (2)  the 
ileo-colic,  in  which  the  in- 
vagination begins  in  the  last 
few  inches  of  the  ileum  (Fig. 
417)  ;  and  (3)  the  ccecal,  in 
which  the  inverted  csecum 
forms  the  apex. 

It    is    not    always    easy, 
however,    in    the    course    of 
an    operation    to    distinguish 
these  varieties  of  intussusception  from  one  another. 

Etiology. — The  subjects  of  intussusception    are    usually    lusty 
children  in  apparently  perfect  health,  but  it  is  generally  possible  to 

elicit  a  history  of  some 
recent  slight  disturbance 
of  the  bowels  in  the  form 
of  constipation  or  diar- 
rhoea, in  which  the  peri- 
staltic function  of  the 
gut  has  been  deranged, 
and  it  is  probably  to  ir- 
regular muscular  contrac- 
tion that  the  commence- 
ment of  the  invagination 
is  due.  A  portion  of  in- 
flamed or  swollen  mucous 
membrane  is  pushed  or 
pulled  towards  the  lumen 
of  the  segment  of  gut  just 
beyond,  and  acts  as  an 
irritant,  setting  up  a  re- 
flex similar  to  that  by 
which  a  bolus  of  food  is 
passed  along  the  bowel. 
The  presence  of  a  polypus, 


Fig.  410. — Double  intussusception. 


ACUTE    INTUSSUSCEPTION    IN    CHILDREN      487 

or  of  an  inverted  Meckel's  diverticulum  01  vermiform  appendix, 
renders  such  an  explanation  of  the  commencement  of  the  invagina- 
tion even  more  easily  understood  (Kg  U8).  The  apex  of  the  in- 
tu-MiMvptioii,  the  first  part  to  be  invaginated,  £01  all  practical 
purpose-  remains  constant,  and,  as  il  soorj  becomes  congested  and 
eedematous,  it  is  impossible    for  more   o\    the  entering   layer  t<>  roll 


Fig.  417. — Illustrating  the  mechanism  by  which  ileo-colic 
intussusceptions  are  formed. 

(Modified  after  /».   C.    L.   Fit 

over  and   become  part    of   the   returning    layer.     The  result  is  that 
the  peristaltic    efforts    of   the    gut   to    force    on  the  apex  drag  the 
sheath  over  the  intussusceptum,  so  that  the  returning  layer  1 
dually  lengthened  and  the  sheath  creeps  up  the  invaginated  portion. 
An  intussusception,  therefore,  increases  at  the  expense  of  the  sheath. 
The  frequency  with  which  the  intussusception  originates  in  the 


THK    INTESTINES 


ileo-csecal  region  is  to  be  explained  by  the  anatomical  and  physiological 
arrangements  of  this  part  of  the  bowel,  the  last  few  inches  of  the  ileum 
acting  as  a  detrusor  muscle  to  pass  the  intestinal  contents  through 
the  ileo-colic  sphincter,  and  being  studded  over  with  numerous  Peyer's 

patches,  which  are  liable  to  become 
inflamed  and  swollen.  The  greater 
size  of  the  lumen  of  the  colon  as 
compared  with  the  ileum,  and  the 
length  and  looseness  of  the  meso- 
colon of  the  infant,  also  favour  the 
folding  of  the  receiving  layer  over 
the  intussusceptum. 

Morbid  anatomy.  —  As  the 
intussusceptum  increases  in  length, 
the  mesentery  is  dragged  in  between 
the  entering  and  returning  tubes, 
and  the  tension  exerted  through  the 
mesentery  causes  the  intussuscep- 
tion to  become  curved  with  its 
concavity  towards  the  mesenteric 
attachment.  At  the  same  time,  the 
whole  intussusception  is  drawn  back 
towards  the  promontory  of  the  sa- 
crum where  the  mesentery  is  at- 
tached, and  swings  round  in  the 
direction  of  the  hands  of  a  watch 
till  it  may  reach  the  left  iliac  fossa. 
In  this  process  the  mesentery  is 
compressed,  twisted,  and  stretched 
to  such  an  extent  that  the  vascular 
supply  of  the  bowel  is  interfered 
with.  At  first  the  venous  return 
is  impeded,  leading  to  engorgement 
and  swelling  of  the  invaginated 
bowel.  As  the  congestion  increases, 
I)] odd  is  extra vasated  into  the  coats 
of  the  bowel,  and  an  excess  of  mucus 
mixed  with  blood  oozes  from  the 
mucous  surfaces  and  is  passed  by 
the  rectum. 

The  effects  of  the  congestion 
are  most  marked  in  the  returning 
tube,  and  towards  the  apex  of  the  intussusception,  which  may  become 
swollen  into  a  knob,  and  this,  together  with  adhesions  formed  between 


Fig.  418. — Adenoma  of  small  in- 
testine causing  intussusception. 


(Museui 


Royal  College  of  Surgeons 
Edinburgh.) 


ACUTE    INTUSSUSCEPTION    IN   CHILDREN      4«9 


ihr  apposed  serous  Burfaoes,  renders  the  intussusception  irreducible. 
The  laxity  of  the  outeT  wall  of  the  caecum  admits  of  its  slipping  Earthei 
down  than  the  reel  of  the  intussusceptum,  so  that   it    may  even  be 

in  advance  of  the  true  apex,  and  alter  reduction   a    oharacteristi" 

""  dimple  "  remains  EOT  a  time  mi  t  lie  lower  and  OUtei  pari  of  t  lie  ca'cal 
wall  (Kg.  419). 

In  time  the  swelling  of  the  implicated  bowel  and  the  contraction 

of  the  sheath  in  its 
attempts  to  expel  t  he 
intussusceptum  oc- 
clude the  lumen  and 
Lead  to  complete  ob- 
struction. 

The  interference 
with  t  lie  nutrition  of 
the  bowel  is  followed 
by  bacterial  invasion 
of  the  coats,  which 
may  determine  gan- 
grene or  lead  to 
peritonitis. 

The  gangrene  af- 
fects first  and  chiefly 
the  returning  tube, 
then  the  entering 
tube,  but  it  rarely  im- 
plicates the  sheath. 
In  a  certain  number 
of  cases  the  whole 
intussusceptum  has 
undergone  necrosis 
and  been  separated 
as  a  blackish-green 
tubular  slough,  vary- 
ing in  length  from  a 
few  inches  to  seve- 
ral feet,  and  recovery 
has  in  very  rare  instances  followed  the  expulsion  of  such  a  slough. 

Clinical  features. — Intussusception  is  the  most  common  cause 
of  acute  obstruction  in  children,  and  the  clinical  picture  is  usually  so 
characteristic  as  to  leave  little  doubt  regarding  the  diagnosis.  Nearly 
75  per  cent,  of  the  cases  occur  during  the  first  year  of  life,  and  about 
70  per  cent,  are  in  boys.  The  subjects  of  this  condition  are,  as  a  rule, 
fine  lusty  infants,  and  are  in  apparently  perfect  health  when  attacked. 


Fig.  419. — To  illustrate  the  dimple  in  the  wall 
of  the  caecum  after  reduction  of  an  in- 
tussusception. 

(After  D.  C.  L.   Fitswilliams.) 


499  THE    INTESTINES 

The  illness  begins  with  an  attack  of  severe  intestinal  colic,  which 
causes  the  child  to  scream  out  and  draw  up  his  knees.  The  face  is 
pale  and  manifests  severe  suffering  ;  the  eyes  are  bright  and  widely- 
opened,  as  in  fear.  Soon  after  the  onset  of  the  pain,  the  child  usually 
empties  the  stomach  by  vomiting,  but  the  vomiting  is  not  severe  or 
persistent,  and  even  in  advanced  cases  it  seldom  becomes  faecal.  The 
lower  bowel  is  often  emptied  also,  the  motion  being  a  normal  one. 
This  is  followed  by  persistent  tenesmus,  a  considerable  quantity  of 
mucus  tinged  with  blood  being  expelled  at  frequent  intervals.  After 
a  time,  the  symptoms  abate,  but  they  soon  recur.  In  the  intervals 
the  patient  may  be  unnaturally  quiet  and  listless,  but  otherwise  appears 
quite  well.  In  most  cases  a  general  anaesthetic  should  be  administered 
to  admit  of  a  satisfactory  examination  of  the  abdomen  and  rectum. 

"When  the  abdomen  is  examined  it  is  often  observed  that  the  right 
iliac  fossa  is  abnormally  empty,  and  a  firm,  sausage-shaped  swelling, 
curved  with  its  concavity  towards  the  umbilicus,  can  be  felt  in  the 
line  of  the  transverse  or  of  the  descending  colon.  The  swelling  may 
be  recognized  to  harden  and  become  more  definite  during  the  spasms 
of  pain.  There  is  seldom  distension  of  the  abdomen  during  the  first 
two  or  three  days. 

The  abdominal  muscles  are  not  rigid,  and,  so  long  as  the  swelling 
is  not  pressed  upon,  the  child  does  not  resent  examination  of  the 
abdomen. 

If  the  intussusception  has  Teached  the  pelvic  colon,  as  it  does  in 
about  25  per  cent,  of  cases,  it  may  be  recognized  on  rectal  examination 
as  a  soft,  conical  mass  with  a  central  slit-like  depression  resembling 
the  os  uteri,  and  the  examining  finger  may  be  stained  with  bloody 
mucus  like  red-currant  jelly.  The  sphincters  are  usually  relaxed, 
but  may  be  in  a  state  of  spasm.  The  intussusception  seldom  pro- 
trudes from  the  anus  in  acute  cases. 

As  time  goes  on,  the  intervals  between  the  attacks  of  eolie  are 
shorter,  the  pain  becomes  continuous,  with  occasional  exacerbations, 
and  the  tenesmus  is  constant. 

The  child  becomes  exhausted,  the  facial  appearance  alters,  dark 
rings  appear  round  the  eyes,  and  the  abdomen  becomes  distended. 
If  infection  of  the  peritoneum  takes  place,  the  abdomen  is  tender 
and  rigid,  and  other  signs  of  peritonitis  develop. 

Differential  diagnosis. — The  only  condition  that  may  be 
mistaken  for  intussusception  in  infants  is  acute  colitis,  which  is 
comparatively  common  at  this  age.  The  more  gradual  onset  of  the 
illness  and  the  presence  of  bile  in  the  matter  passed  from  the  rectum 
suggest  a  diagnosis  of  colitis  ;  in  intussusception  the  onset  is  sudden 
and  the  obstruction  of  the  bowel  prevents  bile  reaching  the  rectum. 

Treatment. — Statistics    show    that    every    hour    of    delay    in 


Strangulation  of  a  loop  of  small  intestine. 

{Museum,   Royal  College  of  Surgeons,   Edinburgh.) 


Plate  93. 


INTUSSUSCEPTION    IN   CHILDREN 

operating  diminishes  the  prospecl  of  recovery.  An  incision  is  made 
over  the  most  prominenl  pari  of  the  swelling,  which  is  usually  either 
in  tic  line  of  the  ascending  colon,  or  in  the  vicinity  of  the  umbili<  us. 
The  opening  should  be  large  enough  to  admit  <>t  ready  ■  the 

invaginated  Begment  ol  bowel,  so  thai  it  may  be  broughl  t<i  the  suri 
with  as  little  handling  as  possible.  In  carrying  oul  reduction  of  the 
invagination,  the  tumour  Bhould  I"-  straightened  oul  as  Ear  as  possible, 
after  which  pressure  is  made  on  the  intussusceptum  by  compressing 
the  Bheath  just  beyond  the  apex.  <m  no  account  Bhould  the  entering 
loop  1"'  pulled  upon,  as  this  involves  considerable  risk  <>t'  tearing  the 
bowel.  As  a  rule,  in  early  cases  reduction  is  easily  effected  in  this 
way;  but  the  last  part  may  be  difficult  to  reduce  on  accounl  of  the 
apex  having  become  oedemat'ous,  in  which  rase,  to  diminish  t  he  oedema, 
it  should  be  gently  squeezed  for  a  few  minutes  through  a  pad  of  m< 
gauze.  When  the  invagination  has  lasted  for  some  considerable  time, 
reduction  may  be  prevented  by  adhesions  between  the  apposed  serous 
surfaces  of  the  entering  and  returning  tubes,  or  by  Bwelling  of  the 
mesentery. 

After  reduction  has  been  effected,  the  whole  length  of  bowel 
implicated  should  be  examined  for  evidence  of  threatening  gangrene 
or  of  damage  to  the  peritoneal  coat.  If  there  is  any  doubt  as  to  the 
viability  of  the  gut,  it  should  be  brought  out  and  an  artificial  anus 
established. 

To  diminish  the  risk  of  recurrence,  a  longitudinal  tuck  or  fold 
may  be  made  in  the  mesentery  of  the  ileum,  or  the  mesentery  may  be 
stitched  to  the  ascending  mesocolon. 

If  it  is  impossible  to  effect  complete  reduction,  or  if,  when  reduced, 
the  bowel  is  found  to  be  gangrenous,  the  affected  segment  must  be 
excised.  By  a  continuous  suture,  the  sheath  and  the  intussusceptum 
are  united  at  the  neck  of  the  intussusception  ;  the  sheath  is  then  in- 
cised longitudinally,  and  the  intussusceptum  removed;  and  the  op< 
tion  is  completed  by  closing  the  opening  in  the  sheath,  or  by  stitching 
it-  edges  to  the  parietal  peritoneum,  and  so  forming  an  artificial  anus. 

If  the  sheath  is  gangrenous,  the  whole  of  the  segment  of  bowel 
implicated  must  be  resected. 

The  mortality  after  all  forms  of  resection,  whether  with  or  without 
the  formation  of  an  artificial  anus,  is  very  high. 

Chronic  Intussusception  in  the  Child 
This  is  usually  of  the  ileo-csecal  variety,  and  the  condition  may  run 
a  very  slow  course,  associated  with  attacks  of  colicky  pain,  irregularity 
of  the  bowels,  and  the  passage  of  blood  in  the  stool-.  Visible  peri- 
stalsis can  sometimes  be  observed,  particularly  after  a  meal,  and  in 
some  cases  a  tumour  can  be  recognized  on  palpation.     This  tumour 


492  THE    INTESTINES 

may  change  its  position  from  time  to  time,  and  sometimes  it  reache: 
the  rectum  and  is  protruded  from  the  anus,  in  which  case  it  may  be 
mistaken  for  a  prolapse  or  a  polypus. 

The  condition  is  treated  on  the  same  lines  as  acute  intussusception 

Acute  Intussusception  in  the  Adult 

In  the  adult,  intussusception  is  a  rare  cause  of  acute  obstruction 
not  more  than  12  per  cent,  of  all  intussusceptions  occurring  in  patient: 
over  10  years  of  age. 

Generally  speaking,  it  may  be  said  that  the  etiology  is  the  same 
as  in  children,  but  more  frequently  some  definite  morbid  conditioi 
of  the  bowel  wall  is  present,  such  as  an  ulcerated  polypus,  a  malig- 
nant tumour,  or  a  diseased  condition  of  the  mucous  membrane,  whiel 
determines  the  invagination. 

There  is,  therefore,  usually  a  long  history  of  gastro-intestina 
disturbance,  which  culminates  in  acute  obstruction.  The  intussuscep- 
tion may  be  of  the  entero-colic  or  of  the  enteric  variety. 

The  clinical  features  are  less  characteristic  than  in  the  child,  and 
the  differential  diagnosis  from  other  causes  of  obstruction  more  diffi- 
cult.    On  the  whole,  the  symptoms  are  less  acute  than  in  children. 

Chronic  Primary  Intussusception  in  the  Adult 

Apart  from  cases  in  which  chronic  intussusception  is  due  to  tumour, 
ulceration,  or  tuberculosis  of  the  bowel  wall,  a  number  of  cases  have 
been  recorded  in  which  the  invagination  was  the  primary  condition 
leading  to  gradual  obstruction  of  the  bowel.  Goodall  of  B 
has  made  a  study  of  the  literature  of  this  Bubject,  based  upon  122 
recorded  cases. 

Morbid  anatomy. — The  intussusception  is  usually  of  the 
entero-colic  variety,  the  enteric  and  colic  forms  being  comparatively 
rare.  As  a  rule,  there  are  numerous  adhesions  between  the  different 
layers,  which  render  reduction  impossible,  but  in  some  cases,  in  >pite 
of  the  fact  that  the  condition  has  lasted  for  weeks  or  even  months, 
there  have  been  remarkably  few  adhesions. 

The  lumen  of  the  gut  may  be  narrowed  to  the  size  of  the  little 
finger  or  even  to  that  of  a  goose-quill,  and  sometimes  a  false  opening 
forms  which  admits  of  the  intestinal  contents  passing  on. 

Ulceration  of  the  mucous  membrane  of  the  coils  implicated  is 
common,  and  the  sheath  frequently  becomes  perforated  at  several 
points,  so  that  portions  of  the  invaginated  bowel  project  through 
it  (Plate  94). 

Clinical  features. — The  condition  is  usually  met  with  in 
persons  between  20  and  40  years  of  age,  and  appears  to  be  twice  as 
common  in  men  as  in  women. 


Chronic  primary  intussusception  in  an  old  man. 

{Author's  case: ) 


Plate  94. 


CHRONIC    INTrsSUSCKPTION    IN    AIM   LTS 


The   symptoms   may  come  <>n  gradually  in  the   form   oi 
iltestiual    disturbance    with   occasiona]    attacks   during   which    there 
is  a  threatening  of  obstruction,  which,  however,  pasa     ofl   in  some 
Lrars.     This  state  of  afEaira  may  Last  over  a  period  ol  months  or  even 
■fears,  and  the  illness  runs  a  very  obscure  course. 

The  most  constant  symptom  is  the  occurrence  of  repeated  attacks 
,,f  abdominal  colic  coming  in  paroxysms,  and  lasting  for  a  period 
which  may  vary  from  a  few  minutes  to  some  hours.  It  is  characteristic 
of  the  pain  thai  at  the  end  of  the  attack  it  disappears  suddenly,  and 
the  patient  is  .it  once  quite  comfortable  again.  This  is  especially  the 
case  in  the  earlier  stages,  and  it  is  attributed  to  the  bowel  becoming 
nisinvaginated  and  to  the  sudden  relief  of  congestion.  In  the  latei 
when  adhesions  have  formed,  the  relief  comes  more  gradually. 
At  first  the  attacks  recur  every  two  or  three  days,  hut  as  tune  goes  on 
the  interval-  become  shorter,  and  there  is  more  or  less  constant  dis- 
comfort, with  periodic  exacerbations  -which  are  frequently  determined 
by  the  taking  of  purgatives  or  unsuitable  food,  or  by  exertion. 

Vomiting  is  seldom  absent  during  an  attack  of  pain,  and  may 
occur  between  attacks;  recovery  has  followed  an  attack  in  which 
the  vomiting  was  distinctly  stercoraceous. 

Constipation  is  not  a  constant  symptom;  in  fact,  there  is  often 
diarrhoea,  the  bowels  moving  three  or  four  times  a  day,  the  motions 
being  watery  and  offensive,  and  containing  much  mucus  and  often 
some  blood.     Tenesmus  is  a  common  symptom. 

The  patient  gradually  becomes  exhausted  from  pain,  is  anxious 
and  depressed,  and  soon  shows  signs  of  ansemia.  Emaciation  may 
be  so  extreme  as  to  suggest  malignant  disease. 

On  examining  the  abdomen,  distended  coils  of  intestine  can  be 
recognized  during  an  attack.  In  the  entero-colic  variety  there  is 
often  a  localized  flattening  of  the  right  iliac  fossa,  while  the  rest  of 
the  abdomen  is  prominent. 

In  the  majority  of  cases  a  localized,  sausage-shaped  tumour  can 
be  made  out.  It  is  usually  ill  defined  towards  its  ends.  It  may  be 
firm  and  elastic,  or  soft  and  doughy  from  faecal  accumulation.  It  is 
characteristic  that  the  tumour  varies  in  shape  and  size  from  time 
to  time,  and  may  even  temporarily  disappear.  In  some  of  the  recorded 
cases  the  tumour  only  appeared  during  an  attack  of  pain,  and  vanished 
with  a  gurgling  sound  when  the  pain  ceased. 

Symptoms  of  acute  obstruction  eventually  supervene,  or  per- 
foration occurs  and  gives  rise  to  peritonitis.  In  a  few  case,  spon- 
taneous separation  of  the  intussusceptum  has  taken  place,  but  this 
has  been  followed  by  stenosis. 

Differential  diagnosis. — The  majority  of  cases  have  hitherto 
been  diagnosed  only  on  opening  the    abdomen,  or    on    post-mortem 


494  THE    [NTESTINES 

examination.  The  conditions  for  which  it  is  most  liable  to  be  mis- 
taken are  cancer  of  the  bowel,  ileo-ceecal  tuberculosis,  colitis,  and 
recurrent  appendicitis. 

Treatment. — The  only  treatment  is  to  open  the  abdomen 
and  deal  with  the  invagination.  Hitherto  the  results  obtained  by 
resection  have  been  satisfactory. 

VOLVULUS 
The  term  "  volvulus  "  is  applied  to  a  condition  in  which  a  segment 
of  bowel  is  twisted  on  its  mesenteric  axis.     It  is  one  of  the  most 
fatal  of  all  forms  of  obstruction. 

Volvulus  of  the  Pelvic  Colon 

The  pelvic  colon  is  the  segment  of  bowel  implicated  in  about  75  per 
cent,  of  cases. 

Etiology. — This  portion  of  the  colon,  which  approximates  in 
shape  to  the  letter  Q,  is  rendered  liable  to  be  twisted  by  the  fact  that 
its  mesentery  is  comparatively  narrow  in  proportion  to  the  length  of 
the  bowel  so  that  the  two  ends  of  the  loop  are  approximated.  The 
loop  varies  in  length  from  about  8  in.  to  2  ft.,  and  the  longer  the  loop 
in  proportion  to  the  width  of  its  mesentery,  the  greater  is  the  liability 
to  volvulus. 

The  secondary  changes  in  the  mesocolon  which  further  prediB] 
to  volvulus  are — (1)  elongation,  such  as  may  result,  for  example,  from 
chronic  constipation — the  overloaded  bowel  by  its  weight  hanging 
down  into  the  pelvis  and  dragging  upon  the  mesentery  ;  (2)  narrowing 
of  the  base  of  attachment  to  the  sacrum,  resulting  in  closer  approxi- 
mation of  the  two  ends  of  the  O-loop,  produced,  for  instance,  by 
inflammatory  adhesions,  by  changes  occurring  in  infected  lymph- 
glands,  or  as  a  result  of  chronic  inflammatory  or  ulcerative  conditions 
in  the  bowel  itself  ;  (3)  ■fixation  of  the  parietal  attachment,  as  a  result 
of  thickening  or  adhesions  clue  to  inflammatory  changes,  forming  an 
axis  around  which  the  bowel  readily  rotates. 

The  actual  twisting  is  usually  brought  about  by  irregular  peristalsis, 
induced,  for  example,  by  overloading  of  the  pelvic  colon  in  chronic 
constipation,  or  by  efforts  on  the  part  of  the  bowel  to  expel  a  hardened 
mass  of  fseces,  or  by  an  excessive  accumulatiou  of  flatus.  The  mere 
weight  of  an  overloaded  sigmoid  may  cause  it  to  fall  into  the  pelvis 
and  twist  its  base.  A  violent  straining  effort,  such  as  making  a  heavy 
lift,  a  sudden  alteration  in  the  intra-abdominal  pressure,  or  even  a 
change  in  the  attitude  of  the  patient   may  induce  rotation. 

As  a  rule,  the  upper*~part  of  the  sigmoid  rotates  downwards  and 
forwards,  so  that  the  rectum  lies  behind  the  twisted  loop  (Fig.  420). 
Less  commonly,  it  passes  backwards,  and  the  rectum  lies  in 


VOLVULUS   OF    PELVIC   COLON 

(Fig.  421).     The  extent   of  the  rotation  varies  from  a   hall-twist — 
180° — to  two  01  even  three  complete  turns. 

Morbid  anatomy.- Tin*  gravity  of  the  condition  depends 
upon  the  tightness  of  the  constriction  at  the  base  of  the  mesentery. 
It'  the  twist  does  ao1  implicate  the  blood-vessels  in  such  a  way  as  to 

occlude  them,  the  symptoms  aTe  those  of  incarcerati c  incomplete 

obsl  ruction  ;  but  if  the  veins  arc  occluded  and  t  be  eel  urn  of  blood  from 
the  implicated  segment  is  interfered  with,  symptoms  of  complete 
obstruction  ensue.  The  twisted  loop  becomes  intensely  congested 
and  oedematous,  and  assumes  a  dark  purple  colour.  Ihemorrhafi 
occur  into  the  tissues,  and  scrum,  mixed  with  blood,  escapes  into  the 
lumen  of  the  gul  and  into  the  peritoneal  cavity.  The  fluid  found  on 
opening  the  abdomen  is  of  a  brownish  chocolate  colour — a  point  of 
some  diagnostic  importance. 

The  twisted  loop  rapidly  becomes  enormously  dilated,  sometimes 
to  such  an  extent  that  it  nearly  tills  the  abdominal  cavity,  pressing 
the  small  intestine  backwards  and  towards  the  right.  The  diaphragm 
may  be  so  pressed  upon  that  the  action  of  the  heart  and  lungs  is 
seriously  impeded.  The  gas  with  which  the  bowel  is  distended  is 
probably  chiefly  carbonic  acid  gas,  which  is  not  absorbed  from  the 
gut  owing  to  the  occlusion  of  the  veins.  Gases  of  putrefaction  are 
also  present,  but  the  rapidity  with  which  distension  occurs  makes  it 
unlikely  that  they  are  the  chief  cause. 

The  dilatation  of  the  sigmoid  may  be  so  great  that  the  longitudinal 
striae  are  not  recognizable  and  the  peritoneal  covering  may  split  and 
gangrene  of  the  gut  take  place.  Under  these  conditions  organisms 
soon  pass  through  the  wall  of  the  bowel  and,  reaching  the  peritoneal 
surface,  set  up  peritonitis,  which  speedily  becomes  generalized.  Although 
patches  of  gangrene  often  form  in  the  distended  bowel,  perforation, 
w  hi  n  it  occurs,  is  usually  above  the  twist. 

Clinical  features. — Volvulus  of  the  pelvic  colon  is  most 
frequently  met  with  in  adults  in  the  prime  of  life,  and  is  four  times 
commoner  in  men  than  in  women.  There  is  generally  a  history  of 
constipation.  The  symptoms  usually  come  on  suddenly,  and  the 
illness  rapidly  assumes  the  characters  of  acute  and  complete  obstruc- 
tion. -There  is  sharp  pain,  with  exacerbations  of  a  colicky  characl 
It  is  generally  referred  to  the  region  of  the  umbilicus,  and  radii 
along  the  colon  to  the  left  iliac  fossa  and  to  the  lumbar  region 
and  back.  In  a  comparatively  short  time  definite  tenderness  can 
be  detected  in  the  left  iliac  fossa,  a  symptom  which  indicates  the 
onset  of  peritonitis.  There  is  frequently  severe  tenesmus,  but 
nothing  is  passed  by  the  bowel.  Vomiting  is  seldom  an  early  or  a 
prominent  symptom,  as  the  seat  of  the  lesion  is  low  down  in  the 
large  intestine,  but  hiccup  and    eructation  of  gas  are  in  many  cases 


496 


THE   INTESTINES 


persistent.     The    initial    shock    is  not    so  severe  as  in  most    of  the 
other  forms  of  acute  obstruction. 

The  most  striking  and  characteristic  local  sign  is  the  early  and 
extreme  degree  of  distension  of  the  abdomen.  Within  a  few  hours 
the  left  side  of  the  belly  becomes  prominent  and  yields  a  uniform 
drummy  note  on  percussion,  the  colon  becomes  so  dilated  that  it 
fills  the  abdomen,  and  the  other  viscera  are  pushed  aside  and  cannot 
be  located  by  percussion.     The  diaphragm  may  be  displaced  up  as 


Fig.  420. — Volvulus  of  pelvic  colon  downwards  and  forwards. 
(Semi -diagrammatic.) 

far  as  the  level  of  the  third  rib,  with  the  result  that  the  circulation 
and  the  respiration  are  seriously  interfered  with.  Visible  peristalsis 
is  exceptional,  as  the  bowel  above  the  twisted  loop  is  so  pressed  upon 
that  it  is  incapable  of  contracting. 

If  unrelieved,  the  condition  usually  proves  fatal  in  two  or  three 
davs  from  peritonitis  due  to  infection  through  the  congested  loop, 
or  to  perforation  of  the  gut  above  the  twist. 

Only  in  rare  cases  is  the  obstruction  incomplete.  In  these,  the 
onset  is  less  acute,  and  faeces  and  flatus  may  be  passed  in  small  quantities, 
or  diarrhoea  even  may  be  present.  In  such  cases,  untwisting  of  the 
bowel  may  occur,  with  relief  of  the  symptoms,  but  the  condition  is 


VOLVULUS   OF    PELVIC    COLON 


497 


liable  to  recui  from  time  to  time  if  the  pelvic  colon  becomes  over- 
loaded. 

Treatment. — When  there  is  reason  to  suspect  the  presence  of 
a  volvulus  within  a  few  hours  of  the  onset  of  obstructive  Bymptoms, 
with  the  patient  in  the  knee-elbow  position  a  long  rectal  tube  may  be 
passed  into  the  colon  to  withdraw  gas  and  fluid.  If  this  is  not  imme- 
diately successful,  it.  need  not  be  repeated,  and  no  time  should  be  lost 
in  opening  the  abdomen.     The  incision   should    be   large  enough  to 


Fig.  421. — Volvulus  of  pelvic  colon  backwards. 
( Semi-diagrammatic.) 

admit  of  free  access  to  the  distended  coil,  and  even  of  its  being  brought 
out  of  the  abdomen.  After  the  abdomen  has  been  opened,  it  may  be 
possible,  with  one  hand  inside,  to  guide  a  rectal  tube  past  the  twist 
and  so  empty  the  distended  loop  of  gas  and  fluid  faeces.  If  successful, 
this  greatly  simplifies  the  further  manipulations  ;  if  it  fails,  the  loop 
must  be  opened  and  the  twist  undone. 

If  the  gut  is  viable,  the  opening  may  be  closed  and  the  loop 
returned  to  the  abdomen  after  any  adhesions  that  may  be  present 
have  been  dealt  with.  It  is  probably  safer,  however,  to  utilize  the 
opening  as  an  artificial  anus  till  the  patient  has  got  over  the  immediate 
effects  of  the  obstruction. 


498  THE   INTESTINES 

Primary  resection  is  indicated  only  when  the  twisted  loop  is  gan- 
grenous, and  then  the  divided  ends  of  the  bowel  should  be  brought 
to  the  surface  and  drained,  a  lateral  anastomosis  being  established  later. 

When  the  volvulus  cannot  be  untwisted,  an  artificial  anus  should 
be  established  in  the  distended  bowel  above,  and  a  tube  inserted  into 
the  twisted  loop  to  drain  it.  If  the  patient  survives,  the  affected 
segment  of  gut  is  subsequently  resected,  and  the  continuity  of  the 
canal  re-established  by  end-to-end  suture  or  lateral  anastomosis. 

Attempts  have  been  made  to  prevent  recurrence  of  volvulus  by 
stitching  the  pelvic  colon  to  the  parietal  peritoneum  or  to  the  iliac 
fossa,  but  these  have  not  proved  successful.  More  satisfactory  results 
have  been  attained  by  shortening  the  mesentery  of  the  pelvic  colon  by 
a  series  of  sutures  introduced  parallel  to  the  bowel,  care  being  taken  not 
to  interfere  with  the  blood  supply  or  to  kink  the  bowel.  If  recurrence 
takes  place,  as  it  frequently  does,  the  pelvic  colon  should  be  excised. 

Other  Forms  of  Volvulus 

The  other  portions  of  the  intestine  that  may  be  the  seat  of  volvulus 
are — (1)  the  ileo-ccecal  junction,  and  (2)  the  small  intestine.  So  long 
as  the  mesenteric  arrangements  of  these  parts  are  normal,  volvulus 
cannot  take  place  ;  but  if  the  mesentery  is  abnormally  long,  or  its  base 
of  attachment  narrowed  or  rendered  rigid,  then  volvulus  may  occur. 

Volvulus  of  the  ileo-csecal  junction. — The  twist  may  be 
limited  to  the  caecum,  or  may  also  involve  the  ascending  colon,  the 
last  part  of  the  ileum,  or  both.  The  conditions  of  occurrence  are  the 
same  as  in  volvulus  of  the  pelvic  colon,  and  the  circumstances  which 
determine  it  similar. 

The  condition  is  less  acute  than  when  the  pelvic  colon  is  twisted. 
Vomiting  is  present,  although  not  severe.  The  distension  is  not  so 
extreme,  and  the  distended  caecum  may  be  recognizable  in  the  right 
loin  and  iliac  fossa,  or  in  the  left  hypochondrium,  as  a  defined  resonant 
swelling  about  the  size  of  a  child's  head.  The  difficulty  of  undoing 
the  twist  is  greater  than  in  volvulus  of  the  pelvic  colon. 

Volvulus  of  the  small  intestine  is  rare.  There  are  usually 
adhesions,  which  fix  the  gut  and  form  an  axis  of  rotation. 

It  may  affect  only  one  loop,  or  the  entire  ileum  may  be  rotated. 
The  rotation  is  usually  in  the  direction  of  the  hands  of  a  watch,  and 
amounts  to  one  complete  turn  or  more. 

The  symptoms  vary  in  severity  with/  the  extent  of  bowel  involved, 
and  the  tightness  of  the  strangulation.  The  twisted  segment  may 
form  a  tangible  mass  in  the  middle  of  the  abdomen.  Vomiting  is 
always  an  early  and  severe  symptom. 

The  treatment  of  these  forms  of  volvulus  is  carried  out  on 
the  same  lines  as  that  of  volvulus  of  the  pelvic  colon. 


GALL-STONE    OBSTRUCTION 

OBSTRUCTION   DUE   TO   IMPACTION    OF   A   GALL-STONE 

The  term  "  gall-stone  ileus,"  or  "  gall-stone  obstruction,"  is  applied 
to  a  rare  condition  in  which  a  large  gall-stone  has  found  its  way  into 
tin-  intestinal  canal  and  become  impacted  there.  The  gall-stone, 
which  has  formed  in  the  gall-bladder  and  has  reached  such  dimensions 
that  it  cannot  pass  along  the  bile-ducts,  sets  up  irritation  which  leads 
to  localized  peritonitis  around  the  gall-bladder  and  duodenum.  The 
adjacent  parts  of  these  viscera  become  adherent,  and  the  pressure  of 
the  gall-stone  leads  to  the  formation  of  a  fistulous  opening  into  the 
first  or  second  part  of  the  duodenum.  It  is  in  this  way  that  the 
majority  of  large  gall-stones  enter  the  bowel,  but  cases  have  been 
recorded  in  which  the  stone  had  so  dilated  the  cystic  and  common 
bile-ducts  that  these  formed  a  continuous  cavity  from  which  it  passed 
directly  into  the  gut. 

In  rare  cases,  the  stone  ulcerates  its  way  directly  into  the  large 
intestine  and  is  passed  with  the  fseces  without  giving  rise  to  obstructive 
symptoms. 

If  the  stone  is  less  than  1  in.  in  diameter,  it  usually  passes  safely 
along  the  intestinal  canal,  but  if  of  larger  dimensions  it  is  liable  to 
be  arrested,  and  the  larger  the  stone  the  higher  up  is  impaction  likely 
to  take  place.  In  the  great  majority  of  cases,  impaction  occurs  in 
the  lower  part  of  the  ileum.  The  occlusion  of  the  bowel  is  due  in  part 
to  the  size  of  the  stone,  and  in  part  to  spasm  of  the  circular  muscular 
fibres  induced  by  the  irritation  caused  by  the  presence  of  a  rough 
foreign  body.  If  the  lumen  of  the  bowel  is  narrowed  by  cicatricial 
contraction  or  malignant  disease,  a  comparatively  small  gall-stone  may 
determine  symptoms  of  acute  obstruction  if  impacted  in  the  orifice. 

Clinical  features. — The  condition  is  most  frequently  met 
with  in  fat  women  between  55  and  65  years  of  age.  There  is  usually 
the  history  that  the  patient  has  suffered  for  years  from  more  or  less 
constant,  dull  epigastric  pain,  with  occasional  exacerbations  which 
have  been  attributed  to  dyspepsia.  Only  in  a  small  proportion  of 
cases  is  there  a  history  of  typical  attacks  of  biliary  colic  associated 
with  jaundice,  doubtless  because  the  stones  that  eventually  cause 
obstruction  are  single,  and  do  not  engage  in  the  common  bile-duct 
or  cause  obstruction  of  its  lumen.  More  recently  the  pain  has  been 
more  severe  and  diffuse,  as  a  result  of  the  localized  peritonitis  and 
ulceration,  associated  with  the  formation  of  the  fistulous  tract  by 
which  the  stone  escapes  into  the  bowel.  At  first,  the  stone  projects 
into  the  duodenum  and  causes  irritation,  which  gives  rise  to  localized 
pain  in  the  right  hypochondrium  and  persistent  vomiting.  As  the 
stone  is  passing  along  the  small  intestine,  the  pain  is  referred  to  the 
umbilicus. 


5oo  THE    INTESTINES 

When  it  becomes  impacted,  vomiting  is  the  most  prominent 
symptom.  It  is  continuous  and  profuse,  and  at  first  the  vomited 
material  may  be  tinged  with  blocd  from  the  fistulous  track  ;  later, 
it  is  bile-stained,  and  it  very  soon  becomes  stereoraceous.  The 
quantity  of  fluid  vomited  far  exceeds  that  taken  by  the  mouth. 

Shock  and  collapse  are  less  marked  symptoms  and  are  more  delayed 
than  in  the  case  of  most  other  forms  of  acute  obstruction,  presumably 
because  the  vascular  and  nervous  mechanisms  of  the  intestine  are 
not  interfered  with.  Arrest  of  the  passage  of  faeces  and  flatus  is  not 
a  constant  symptom  at  the  beginning  of  the  illness.  As  the  displace- 
ment of  the  stone  from  the  duodenum  is  often  brought  about  by  the 
taking  of  a  strong  purge,  the  bowels  may  ral  times  after  the 

onset  of  the  pain  and  vomiting,  and  this  is  apt  to  be  misleading  in 
diagnosis.  After  the  stone  becomes  firmly  impacted,  however,  con- 
stipation is  complete.  Tenderness  and  rigidity  of  the  abdomen  are 
not  marked,  and  distension  is  usually  slight  and  not  easily  recognized 
owing  to  the  obesity  of  the  patient.  It  is  sometimes  possible  to  palpate 
the  stone  through  the  parietes  or  from  the  rectum  while  the  patient 
is  under  an  anaesthetic. 

The  diagnosis  is  always  a  matter  of  great  difficulty,  and  is 
seldom  made  with  certainty  before  the  abdomen  is  opened,  doubtless 
because  the  possibility  of  this  cause  for  the  symptoms  is  often  over- 
looked. The  late  H.  L.  Barnard,  who  had  an  extensive  experience 
of  this  condition,  laid  great  stress  upon  the  unusual  character  of  the 
grouping  of  the  symptoms  as  an  aid  in  diagnosis. 

Treatment. — As  in  other  forms  of  acute  obstruction,  the  only 
rational  treatment  is  to  remove  the  stone  by  operation,  and  the  high 
mortality  in  this  form  of  obstruction  is  chiefly  due  to  delay  in  operating, 
although  in  addition  the  age  and  obesity  of  the  patients  render  them 
unfavourable  subjects  for  operation. 

If  this  cause  is  suspected,  the  abdomen  should  be  opened  to  one 
or  other  side  of  the  middle  fine  below  the  umbilicus,  and  the  lower 
part  of  the  cavity  explored.  As  a  rule,  the  cause  of  the  obstruction 
is  speedily  discovered,  as  the  stone  is  usually  impacted  low  down  in 
the  ileum.  If  not,  the  ileo-eeecal  junction  should  be  found  and  the 
intestine  traced  upwards  from  it.  When  distended  bowel  predomi- 
nates, the  first  presenting  coil  should  be  traced  towards  the  right  until 
the  stone  is  reached.  The  occluded  loop  is  then  withdrawn  from  the 
wound  and  packed  off  with  gauze,  and  opened  in  the  long  axis  of 
the  gut.  The  bowel  is  opened  at  some  distance  above  the  seat  of  im- 
paction. The  stone  having  been  removed  and  the  distended  bowel 
emptied,  the  opening  is  closed  by  a  Czerny-Lembert  suture  inserted 
at  right  angles  to  the  long  axis  of  the  bowel.  In  some  cases  it  has 
been  necessary  to  resect  the  loop  of  bowel  implicated. 


ENTEROLITHS 


501 


If  operation  is  impracticable,  01  is  refused,  belladonna  and  opium 
may  be  given  to  relieve  the  symptoms. 

A  chronic  form  of  gall-stone  obstruction  has  1 q  described, 

in  which  the  patienl  Buffers  from  intermittent  attacks  of  colicky  pain 
with  temporary  incomplete  obstruction,  due  to  blocking  of  different 
parts  of  the  gul  as  the  stone  passes  along.  Such  attacks  may  occur 
at  intervals  of  days  or  weeks,  ami  any  one  of  them  may  become  acute. 

ENTEROLITHS,    INTESTINAL   CALCULI,    OR    F.K<  A  I. 
CONCRETIONS    AND    ACCUMULATIONS 

Solid  masses  composed  of  phosphates  of  lime  and  magnesia,  or 
triple  phosphates,  sometimes  mixed  with  carbonate  of  lime,  ammonia, 


•**? 


Fig.  422. — Enterolith  impacted  in  intestine. 

{From  a  photograph  lent  by  Dr.    T.    Mac  hardy.) 

or  soda,  frequently  form  in  the  intestinal  canal,  particularly  under 
conditions  in  wThich  there  is  a  long-continued  catarrh  of  the  bowel. 
Such  enteroliths  are  often  of  stony  hardness,  but  they  seldom  attain 
great  dimensions.  A  similar  form,  composed  chiefly  of  insoluble  drugs, 
such  as  magnesia,  salol,  bismuth,  or  chalk,  which  the  patient  has 
been  taking  medicinally  over  a  long  period,  is  sometimes  met  with. 
A  third  variety,  not  so  hard  as  the  others,  is  composed  chiefly  of  the 
indigestible  residue  of  certain  vegetable  foods,  notably  oatmeal. 

"When  such  an  adventitious  object  is  arrested  for  a  time  in  the  lumen 
of  the  bowel  or  in  a  cul-de-sac  in  its  wall,  it  gives  rise  to  a  degree  of 


502  THE   INTESTINES 

chronic  enteritis,  and  the  inflammatory  products  resulting  from  the 
irritation  of  the  mucous  membrane  favour  the  adhesion  of  faecal 
particles  and  lead  to  a  gradual  increase  in  the  size  of  the  concretion. 
While  these  different  concretions  vary  in  composition,  they  have 
this  in  common,  that  they  usually  form  on  a  nucleus  of  some  organic- 
substance,  such  as  a  fruit-stone,  a  mass  of  hairs,  or  a  gall-stone. 

Enteroliths 

Clinical  features. — It  is  exceedingly  rare  for  an  enterolith 
to  give  rise  to  acute  obstruction  unless  it  is  suddenly  displaced  from 
a  diverticulum  and  becomes  impacted  in  the  lumen  of  the  gut,  and 
then  the  symptoms  are  similar  to  those  of  gall-stone  ileus  (p.  499). 

While  a  concretion  is  in  process  of  formation  in  the  ileum,  it  may 
give  rise  to  symptoms  associated  with  enteritis — recurring  attacks 
of  colicky  pain,  vomiting,  and  diarrhoea,  usually  coming  on  two  or 
three  hours  after  a  meal,  and  if  ulceration  of  the  mucous  membrane 
has  occurred,  the  motions  may  be  stained  with  blood.  As  it  increases 
in  size,  it  causes  repeated  mild  obstructive  attacks,  attended  with  con- 
stipation and  a  moderate  degree  of  distension,  sometimes  with  visible 
peristalsis  and  severe  vomiting.  A  palpable  swelling,  which  is  tender 
on  pressure,  may  be  recognizable  in  the  lower  part  of  the  abdomen. 

When  the  calculus  forms  in  the  colon,  the  prominent  symptoms 
are  severe  colic  with  tenesmus,  and  the  passage  of  watery  stools  con- 
taining mucus,  pus,  and  sometimes  blood.  As  the  most  common  site 
is  in  the  caecum,  the  concretion  may  reach  a  considerable  size,  and  can 
be  felt  as  a  rounded  hard  movable  mass  in  the  right  iliac  fossa,  which 
is  tender  on  pressure.  A  calculus  situated  in  the  colon  seldom  gives 
rise  to  acute  obstructive  symptoms. 

The  treatment  consists  in  opening  the  abdomen,  usually  in 
the  right  iliac  fossa,  removing  the  concretion,  and  closing  the  bowel. 

It  is  more  than  doubtful  if.  as  has  been  alleged,  an  accumulation 
of  intestinal  worms  ever  causes  obstruction  of  the  bowels,  the  so-called 
ileus  verrninosus. 

F.LCAL    A<  CUMULATIONS 

We  are  here  concerned  only  with  that  degree  of  habitual  con- 
stipation which  leads  to  an  accumulation  in  the  rectum  and  colon 
of  faecal  masses,  which  become  impacted  in  the  bowel  and  may 
eventually  cause  complete  obstruction.  Considering  the  frequency  of 
obstinate  constipation,  it  is  remarkable  how  seldom  the  bowel  becomes 
obstructed  by  accumulated  faeces. 

As  a  rule,  the  clinical  picture  is  one  of  gradually  increasing  obstruc- 
tion, and  it  is  probable  that  it  is  only  when  some  additional  factor, 
such  as  kinking  or  rotation  of  the  overloaded  pelvic  colon,  is  super 
added  that  acute  symptoms   supervene.      In    some    cases    the    onset 


FMCAL   ACCUMULATIONS  503 

of  complete  obstruction  is  precipitated  by  the  taking  of  a  violent 
purgative. 

Morbid  anatomy. — The  masses  that  block  the  bowel  may 
he  angle  or  multiple,  and  they  vary  in  consistence  from  a  putty-lik*- 
substance  to  a  body  of  stony  hardness.  They  usually  form  in  the 
pelvic  colon,  but  may  eventually  fill  the  rectum,  and  extend  into 
the  ascending  and  transverse  portions  of  the  colon. 

By  their  weight  they  may  drag  upon  the  pelvic  colon  so  that  it 
sinks  down  into  the  pelvis,  and,  by  pressing  upon  the  rectum,  adds 
to  the  difficulty  of  emptying  the  bowel.  The  traction  on  the  meso- 
colon causes  it  to  elongate,  and,  by  narrowing  its  base  of  attachment, 
predisposes  to  volvulus,  which,  if  it  occurs,  sets  up  symptoms  of 
acute  obstruction.  If  the  transverse  colon  is  overloaded,  it  similarly 
is  dragged  down  and  forms  a  U-  or  V-shaped  loop,  which  may  reach 
the  level  of  the  pubes. 

The  pressure  of  tin1  hardened  masses  on  the  mucous  membrane 
leads  to  ulceration — stercoral  ulcers — the  mucosa  becoming  eroded  in 
patches  (p.  521). 

Clinical  features. — The  condition  is  most  commonly  seen  in 
elderlv  women  who  have  for  years  suffered  from  constipation.  As 
the  bowel  becomes  loaded,  there  is  a  constant  feeling  of  abdominal 
discomfort,  the  digestive  functions  are  disturbed,  there  are  flatulence 
and  an  unpleasant  taste  in  the  mouth,  and  the  breath  has  an  offensive 
odour.  The  skin  may  assume  a  dirty-greyish  colour,  giving  the  patient 
a  swarthy  appearance,  and  the  pigment  is  sometimes  deposited  in 
patches.  The  patient  suffers  from  painful  tenesmus,  due  to  the 
excessive  efforts  of  the  bowel  to  expel  its  contents,  and  when  ulcera- 
tion is  present  there  are  occasional  attacks  of  spurious  diarrhoea  with 
the  passage  of  sanious,  muco-purulent  discharge.  The  absorption 
of  toxins  is  associated  with  a  certain  degree  of  febrile  disturbance  ; 
the  patient  emaciates,  and  becomes  dull  and  lethargic,  or  even  mentally 
depressed  and  melancholic. 

On  examination,  a  swelling  can  be  felt  in  the  line  of  the  colon, 
which  is  usually  distended.  There  is  tenderness  on  making  firm 
pressure  over  it,  and  the  faecal  mass  may  pit  on  pressure. 

On  rectal  examination,  hard  scybalse,  or  a  soft  pultaceous  mass, 
can  sometimes  be  felt. 

When  acute  obstruction  supervenes  there  is  intense  colicky  pain, 
and  great  distension  of  the  intestines,  which  may  displace  the  other 
abdominal  and  pelvic  viscera  and  may  even  interfere  with  the  action 
of  the  heart  and  respiration.  Vomiting  is  a  common  symptom,  but 
it  is  seldom  urgent,  and  is  rarely  fsecal.  The  patient  becomes  collapsed, 
and,  unless  relief  is  obtained,  the  condition  proves  fatal,  in  the  same 
way  as  in  other  forms  of  complete  obstruction. 


5<M  THE   INTESTINES 

Treatment. — Before  the  onset  of  acute  obstructive  symptoms, 
to  soften  the  scybalous  masses  and  to  lubricate  the  passage,  several 
ounces  of  warm  olive  oil  should  be  introduced  into  the  bowel  by  means 
of  a  soft  tube  and  funnel,  and  after  an  interval  a  large  turpentine 
enema  is  administered. 

It  is  often  necessary  to  break  down  the  hardened  masses  mechanically, 
and  this  is  best  done  under  an  ansesthetic.  The  patient  is  placed  in 
the  lithotomy  position,  the  anal  sphincter  is  stretched,  and  with  the 
gloved  hand  the  scybalous  masses  are  broken  down,  and  then  washed 
out.  If  there  is  evidence  of  stercoral  ulceration,  great  care  must 
be  taken  that  the  bowel  be  not  perforated  in  this  procedure. 

When  symptoms  of  acute  obstruction  are  present,  the  abdomen 
must  be  opened  and  an  artificial  anus  established.  After  the  upper 
bowel  has  been  emptied,  the  feecal  accumulation  may  be  softened 
and  removed  by  injections  made  through  the  artificial  opening  as  well 
as  by  the  anus. 

Surgical  treatment  of  habitual  constipation. — Apart 
from  those  cases  in  which  habitual  constipation  culminates  in  a 
fsecal  obstruction  of  the  bowel,  attempts  have  been  made  to  relieve 
the  patient  of  the  discomfort  and  ill-health  induced  by  the  chronic 
condition  of  the  colon  by  surgical  measures.  The  separation  of 
adhesions  between  the  colon  and  the  parietes  or  adjacent  viscera, 
which  interfere  mechanically  with  the  peristaltic  action  of  the  bowel, 
is  often  followed  by  marked  improvement.  Mansell-Moullin  has 
suggested  and  practised  ileo-colostomy  with  some  degree  of  success, 
but  this  operation  is  not  always  feasible,  and  has  not  proved  very 
satisfactory. 

Complete  excision  of  the  colon  has  been  advocated  by  Arbuthnot 
Lane,  the  ileum  being  connected  with  the  rectum,  either  by  end-to-end 
suture  or  by  lateral  anastomosis. 

In  a  certain  number  of  cases  it  has  been  found  that  habitual  con- 
stipation has  been  due  to  an  hypertrophied  condition  of  the  rectal 
valves  of  Houston,  and  that  removal  of  these  thickened  folds  of 
mucous  membrane  by  means  of  the  knife  or  cautery  has  effected  a 
cure  of  the  condition. 

POSTOPEKATIVE   OBSTRUCTION 

This  term  is  here  used  in  relation  to  that  form  of  acute  obstruction 
which  is  an  immediate  and  direct  result  of  operation,  and  is  mainly 
due  to  paralysis  of  the  intestine.  Obstruction  due  to  strangulation 
by  bands  or  to  other  mechanical  effects  of  peritoneal  adhesions  resulting 
from  a  previous  operation  is  described  elsewhere  (pp.  478,  480). 

After  abdominal  operations,  the  bowel  may  become  distended  with 
gas,  which  the  patient  is  unable  to  expel,  either  on  account  of  a  spasm 


POSTOPERATIVE   OBSTRUCTION 

of  the  ana]  sphincters  or  because  of  pain  in  the  abdominal  wound 
when  he  strains.  As  the  flatus  accumulates,  the  bowel  is  gradually 
Btretched,  and  its  muscular  coal  loses  its  tour  ami  becomes  paralysed. 
Paralysis  of  the  bowel  with  symptoms  of  complete  obstruction  some- 
times follows  prolonged  operations  in  which  there  has  been  exc< 
handling  of  the  gut  or  forcible  retraction  of  the  edges  of  the  wound. 
It  is  most  liable  to  ensue  if  a  large  amount  of  bowel  has  had  to  be 
withdrawn  from  the  abdominal  cavity  and  the  exposed  coils  have  not 
been  kept  moist  and  warm. 

In  cases  of  localized  sepsis — for  example,  appendicitis  with  ab- 
scess formation — there  is  often  difficulty  in  securing  an  action  of 
the  bowels  for  some  days  after  the  operation.  This  may  be  due 
to  paralysis  of  the  loops  of  bowel  in  the  vicinity  of  the  ab 
or  to  adjacent  coils  being  glued  together  by  plastic  lymph  to  such 
an  extent  that  the  peristaltic  waves  are  arrested  by  the  adhe- 
sions. Sometimes  the  obstruction  is  accounted  for  by  too  tight 
packing  with  gauze,  or  the  pressure  of  a  rigid  drainage-tube  on 
the  bowel. 

The  most  common  and  most  serious  cause  of  postoperative  obstruc- 
tion is  general  peritonitis,  which  may  be  due  to  spread  of  the  disease 
for  which  the  operation  was  performed,  or  to  infection  introduced 
at  the  operation.  Occasionally,  embolism  or  thrombosis  of  the 
mesenteric  vessels  causes  paralytic  obstruction. 

Clinical  features. — The  most  prominent  symptoms  are 
gradually  increasing  distension  of  the  abdomen  and  a  progressive 
rise  in  the  pulse-rate.  Sooner  or  later,  mouthfuls  of  brown,  fetid 
fluid  regurgitate  from  the  stomach  almost  continuously  without 
retching  or  effort.  In  some  cases,  the  fluid  collects  in  the  stomach 
for  some  hours  and  is  ejected  in  large  quantities,  the  emptying  of  the 
stomach  giving  great  relief  for  a  time.  Occasionally  no  vomiting 
occurs  till  just  before  death,  when  a  large  quantity  of  brown,  foul- 
smelling  material,  often  mixed  with  blood,  is  brought  'up.  The  tem- 
perature usually  remains  persistently  subnormal.  Abdominal  pain 
and  colic  are  seldom  complained  of,  and  there  is  often  an  entire  absence 
of  muscular  rigidity.  The  extremities  soon  become  cold,  blue,  and 
clammy,  although  the  rest  of  the  body  may  maintain  its  warmth. 
The  features  are  drawn  and  pinched,  but  the  eyes  are  often  bright 
and  clear,  and,  although  the  patient  looks  extremely  ill,  he  may  express 
himself  as  feeling  quite  comfortable,  and  he  usually  fails  to  realize 
the  gravity  of  his  condition.  It  is  seldom  possible  to  distin 
between  the  paralytic  and  the  mechanical  forms. 

Acute  dilatation  of  the  stomach  or  gastro-mesenteric  ileus  may 
closely  simulate  postoperative  obstruction. 

Treatment. — In  the  early  stages  of  abdominal  distension   the 


506  THE    INTESTINES 

introduction  of  a  flatus  tube  into  the  rectum,  or  the  administration 
of  a  turpentine  or  glycerine  enema  with  Epsom  salts,  is  usually  sufficient 
to  relieve  the  discomfort.  If  these  measures  fail,  a  hypodermic 
injection  of  o1,,  gr.  of  eserin,  combined  with  ji,,  gr.  of  atropin,  often 
stimulates  the  peristalsis.  Pituitary  extract  sometimes  acts  in  the 
same  way. 

If  the  abdominal  wound  has  been  packed  or  drained,  it  should  be 
dressed,  and  the  gauze  or  tube  removed. 

Great  relief  often  follows  washing  out  the  stomach.  Purgatives 
must  not  be  given  by  the  mouth,  as  they  only  increase  the  amount 
of  fluid  matter  in  the  paralysed  intestine,  and  large  enemata  should 
be  avoided,  as  they  are  liable  to  be  retained. 

If  the  symptoms  become  worse,  the  wound  should  be  reopened, 
and,  if  no  definite  cause  for  the  obstruction  be  found,  or  if  it  cannot 
be  removed,  an  artificial  anus  must  be  formed  to  drain  the  bowel. 
It  may  be  necessary  to  open  the  intestine  at  several  places. 

EMBOLISM   AND    THROMBOSIS    OF    THE   MESENTERIC 
BLOOD-VESSELS 

The  clinical  picture  in  these  conditions  is  one  of  acute  intestinal 
obstruction  of  the  paralytic  type,  and  a  diagnosis  is  seldom  made 
before  the  abdomen  is  opened. 

The  pathological  appearances  and  the  clinical  symptoms  are  much 
the  same  whether  the  obstruction  is  in  the  mesenteric  artery  or  in 
the  vein.  The  severity  of  the  affection  varies  with  the  site  and 
extent  of  the  vascular  interference,  but  even  when  only  a  limited 
area  of  bowel  has  its  blood-vessels  interfered  with  the  condition  is 
a  grave  one. 

The  patient  is  usually  a  man  between  30  and  60  years  of  age,  who 
suffers  from  infective  endocarditis,  mitral  stenosis,  or  cirrhosis  of 
the  liver.  Without  warning,  the  general  symptoms  of  acute  intes- 
tinal obstruction  suddenly  develop,  but  there  is  often  diarrhoea, 
the  patient  passing  considerable  quantities  of  blood,  but  getting  no 
relief  from  movement  of  the  bowels.  There  is  likewise  blood  in 
the  vomit. 

If  the  abdomen  is  opened,  it  is  found  to  contain  a  considerable 
quantity  of  dark,  blood-stained  fluid  ;  and  the  affected  segment  of 
intestine — varying  from  a  few  inches  to  the  whole  length  of  the  small 
intestine  and  even  part  of  the  colon — is  found  of  a  dark  chocolate 
colour,  firm,  swollen,  and  cedematous.  When  the  condition  has  lasted 
for  some  time,  the  bowel  shows  signs  of  gangrene,  and  there  is  more 
or  less  generalized  peritonitis. 

The  condition  usually  proves  fatal  in  a  few  hours,  and  little  benefit 
has  followed  excision  of  the  affected  portion  of  bowel. 


OBSTRUCTION    FROM    SPASM 

ENTEROSPASM 

The  term  " enterospasm "  has  been  applied  to  .1  condition  in 
which,  as  a  result  of  spasmodic  contraction  of  the  circular  fibres  of  a 
limited  -''input  of  the  bowel,  symptoms  suggestive  nf  acute  intestinal 
obsl  ruction  develop. 

Clinical  features.  The  condition  is  chiefly  mel  with  in 
neurotic  women,  between  20  and  50  years  ol  age,  who  have  suffered 
from  chronic  colitis  with  diarrhoea  and  blood-stained  stools,  <>r  who 
have  recently  undergone  a  pelvic  operation.  Wit  hunt  obvious  cause, 
the  patient  is  seized  with  severe  abdominal  pain  attended  with  vomit- 
ing, distension  of  the  abdomen,  and  complete  arrest  <>f  th<-  passage  of 

es  and  flatus.  The  attack  may  last  for  a  few  hours  or  for  several 
days,  and  then  pass  off  as  suddenly  as  it  began,  and  after  the  bowels 
have  acted,  the  patient  again  feels  perfectly  well. 

During  the  attack,  a  firm,  sausage-shaped  swelling  can  sometimes 
be  made  out  in  the  position  of  the  contracted  gut,  which  is  usually 
the  pelvic  colon. 

In    its   less   severe    forms,   in   which    there   are    merely  repeated 
-harp   attacks  of  colicky  pain,   with   moderate   flatulent  dis- 
tension,  lasting  for  an  hour  or  two,  and  then  passing  off  completely, 
the  condition  is  suggestive  of  recurrent  appendicitis,  renal  or  bili 
colic. 

It  is  characteristic  of  the  affection  that  full  doses  of  belladonna 
and  byoscyamus  rapidly  relieve  the  spasms,  and  the  symptoms  dis- 
appear.    Opium  acts  in  the  same  way,  but  should  only  be  given  for 
diagnostic  purposes  when  there  is  reasonable  certainty  that  no  organic 
of  obstruction  exists. 

Etiology. — The  true  nature  of  these  attacks  has  only  been 
recognized  within  recent  years  as  a  result  of  laparotomy  having  been 
performed  for  the  relief  of  what  was  believed  to  be  an  organic 
obstruction.  A  careful  search  for  the  cause  of  the  obstruction  has 
only  revealed  a  firm  contraction  of  a  portion  of  the  bowel — usually  the 
pelvic  colon — varying  in  length  from  one  to  several  inches.  Above 
the  contracted  segment,  which  is  pale,  firm,  and  rigid,  the  bowel  is 
distended  with  gas  and  faeces,  and  below,  it  is  contracted  and  empty. 
In  some  cases  the  spasm  has  relaxed  and  come  on  again  while  the 
bowel  was  actually  under  observation. 

In  view  of  the  almost  constant  history  of  chronic  colitis  with  blood 
in  the  stools,  it  is  probable  that  the  spasm  is  set  up  by  some  local 
lesion  of  the  mucous  membrane,  such  as  an  ulcer. 

Treatment. — It  must  be  emphasized  that    enterospasm    giving 
rise  to  symptoms  so  severe  as  to  suggest  acute  obstruction  is  n 
and  that  treatment  directed  towards  relief  of  spasm  alone  is  seldom 
justified,  and  is  only  to  be  adopted  when  the  various  causes  of  organic 


5o8  THE    INTESTINES 

obstruction  can  be  definitely  excluded.  If  any  doubt  remains,  an 
exploratory  laparotomy  should  be  performed. 

The  use  of  morphia  and  other  opiates  should  be  avoided  in  view 
of  the  neurotic  temperament  of  most  of  these  patients,  and  if  one  full 
dose  fails  to  give  relief,  the  diagnosis  of  enterospasm  has  almost  cer- 
tainly been  wrong. 

Belladonna,  hyoseyamus,  and  similar  drugs  relieve  the  spasms  in 
true  enterospasm,  and  their  use  may  be  supplemented  by  hot  baths. 
Any  coexisting  inflammatory  affection  of  the  colon  must,  of  course, 
be  treated. 

INFLAMMATORY    AFFECTIONS 

CHRONIC    COLITIS 

The  term  "  chronic  colitis  "  is,  for  convenience,  applied  to  a  con- 
dition in  which  the  patient  complains  of  recurring  attacks  of  severe 
colicky  pain,  associated  with  the  passage  of  an  excessive  amount  of 
mucus  in  the  stools,  without  there  being  any  gross  pathological  lesion 
to  account  for  the  symptoms. 

It  cannot  be  too  strongly  emphasized  that  a  diagnosis  of  "  chronic- 
colitis  "  should  never  be  made  until  all  the  other  affections  of  the 
bowel  that  may  give  rise  to  a  similar  train  of  symptoms  have  been 
excluded.  These  include  malignant  disease  (p.  527),  tuberculosis 
either  of  the  hypertrophic  or  of  the  ulcerative  type  (P-  510),  fibro- 
matosis of  the  colon  (p.  515).  chronic  appendicitis  (p.  552),  and  localized 
peritonitis,  or  abscess  in  the  vicinity  of  the  colon. 

Clinical  features. — The  severity  of  the  symptoms  varies  in 
different  cases,  and  even  in  the  same  patient  at  different  times,  and 
the  disease  tends  to  run  a  protracted  course. 

In  the  less  severe  form,  which  is  the  form  usually  met  with  in  men 
who  show  no  signs  of  neurasthenia,  and  are  in  other  respects  healthy, 
the  patient  complains  of  persistent  abdominal  discomfort,  not  amount- 
ing to  pain,  particularly  after  meals.  The  appetite  is  poor,  and  there 
is  a  tendency  to  constipation  with  flatulent  distension.  There  are; 
however,  occasional  attacks  of  looseness  of  the  bowels  with  pain  and 
tenesmus,  the  motions  consisting  largely  of  mucus.  The  patient 
loses  flesh  rapidly,  and  often  becomes  markedly  depressed  or  even 
melancholic.  The  local  symptoms  may  be  referred  to  the  right  iliac 
fossa,  and  it  is  then  difficult  to  distinguish  this  condition  from  chronic 
appendicitis,  with  which  indeed  it  is  often  associated,  but  whether 
as  cause  or  effect  it  is  impossible  to  say. 

The  more  severe  and  typical  form  is  most  frequently  met  with  in 
middle-aged  women  belonging  to  the  upper  classes,  of  a  markedly 
neurotic  temperament  and  in  a  poor  state  of  health.  It  is  common 
to  find  some  uterine  displacement  or  evidence  of  other  pelvic  disease 


CHRONIC   COLITIS  509 

in  such  subjects.    The  patienl   Buffers  from  chronic  dyspepsia   with 
hyperacidity,  and  is  habitually  constipated,  bu1   baa  periodic  atl 

ere  colicky  pain,  attended  with  sickness  and  vomiting,  and  cul- 
minating in  a  spurious  diarrhoea  with  the  of  large  quantities 
of  mucus  intimately  mixed  with  some  pale  fseoulenl  matter,  containing 
less  than  the  normal  amount  of  bile.  The  mucus  is  sometimes  cleai 
like  white  of  egg  or  boiled  sago,  sometimes  in  flaky  shreds,  and  some- 
times ir  takes  the  form  of  fibrinous  casts  of  the  bowel,  which  may  be 
several  inches  long.  If  broken  up  into  strips,  these  a  pi  to 
be  mistaken  by  the  patient  for  intestinal  worms.  There  is  usually 
a  moderate  amount  of  blood  in  the  motions,  and  occasionally  intestinal 
sand  is  present.  Sometimes  the  patient  loses  a  considerable  quantity 
of  blood — hemorrhagic  colitis. 

During  an  attack,  tenderness  can  usually  be  located  on  making 
pressure  over  the  colon,  and  the  bowel  may  be  felt  to  contract  under 
the  fingers,  forming  a  firm,  elongated,  sausage-shaped  swelling.  There 
is  an  absence  of  muscular  rigidity.  On  examining  the  pelvic  colon 
with  the  sigmoidoscope,  the  mucous  membrane  may  be  found  to  be 
inflamed  or  ulcerated,  and  is  covered  with  patches  of  shreddy  mucus. 

These  acute  attacks  may  recur  every  few  weeks  or  months,  but 
in  the  intervals  the  patient,  as  a  rule,  does  not  regain  strength,  and 
often  becomes  extremely  emaciated.  The  absorption  of  toxins  affects 
the  nervous  system,  and  aggravates  the  neurasthenic  tendencies  of 
the  patient,  who  eventually  passes  into  a  condition  of  chronic  invalidism. 

Treatment. — Medical  and  dietetic  treatment  should  always 
have  a  fair  trial  before  recourse  is  had  to  operative  measures.  To 
relieve  the  acute  symptoms  during  one  of  the  paroxysmal  attacks 
a  hypodermic  injection  of  morphia  with  atropine  should  be  given  to 
relax  the  spasm  of  the  cclon  ;  then,  the  patient  being  placed  in  the 
knee-elbow  position  and  directed  to  retain  the  enema  as  long  as 
possible,  about  a  pint  of  warm  olive  oil  is  slowly  injected  into  the 
colon  ;  after  an  hour  or  two,  the  colon  is  washed  out  with  saline 
solution. 

To  correct  the  irritability  of  the  colon,  the  patient  must  be  put  on 
a  carefully  selected  diet.  According  to  von  Xoorden — and  my  experi- 
ence agrees  with  his — the  diet  should  be  a  full  one,  and  should  consist 
of  such  things  as  fruit,  vegetables,  brown  bread,  and  a  moderate 
amount  of  butcher's  meat,  which  leave  a  considerable  indigestible 
residue.  To  prevent  constipation  and  to  render  the  faeces  soft,  a 
liberal  allowance  of  fatty  food  should  be  given  in  the  form  of  cream, 
butter,  cod-liver  oil  emulsion,  or  petroleum  preparations. 

The  local  treatment  consists  in  injecting  from  6  to  8  oz.  of  warm 
•olive  oil  into  the  colon  every  night.  This  is  to  be  retained  till  morning, 
when  the  bowel  is  washed  out  with  saline  solution.     The  inflammation 


5i°  THE   INTESTINES 

of  the  mucous  membrane  may  be  allayed  by  injections  of  one  or  other 
of  the  albuminous  silver  preparations,  such  as  protargol  or  org 
(\  to  1  per  cent.). 

Purgatives  should  be  avoided  if  possible.  If  they  cannot  be  di>- 
pensed  with  entirely,  a  small  dose  of  castor  oil  should  be  taken 
regularly  every  four  or  five  days  till  the  tendency  to  constipation  has 
been  overcome. 

When  such  measures  are  ineffectual,  operative  interfere!* 
necessary.  The  best  results  have  followed  appendicostomv.  the 
appendix  being  brought  out  in  the  right  iliac  fossa  and  used  as  a  means 
of  irrigating  the  colon.  Several  pints  of  warm  saline  solution  are 
injected  into  the  colon  through  the  artificial  opening  two.  three  or 
four  times  a  day.  As  a  rule,  no  antiseptic  need  be  added,  but  benefit 
is  sometimes  derived  from  the  silver  salts.  The  irrigation  mat 
kept  up  for  several  months,  and  the  opening  then  allowed  to  close, 
which  it  usually  does  soon  after  the  use  of  the  injections  is  discontinued. 
During  the  treatment,  the  patient  is  able  to  continue  his  work  and  is 
seldom  incommoded  by  the  fistulous  opening. 

This  procedure  should  be  tried  before  recourse  is  had  to  right 
inguinal  colostomy  or  ileo-sigmoidostomy. 

PERICOLITIS 

Diverticulitis 

Changes  similar  to  those  which  occur  in  the  vicinity  of  the  caecum 
as  a  result  of  appendicitis  are  frequently  met  with  around  other  parts 
of  the  colon.  These  are  most  common  in  relation  to  the  pelvic  colon, 
and  are  generally  due  to  infective  processes  originating  in  acquired 
diverticula — so-called  diverticulitis. 

The  formation  of  a  concretion  in  a  diverticulum  may  be  followed 
by  ulceration  or  suppuration,  and  if  the  infective  process  spread-  to 
the  peritoneum,  a  localized  abscess  may  form  or  a  general  peritonitis 
be  set  up. 

Similar  results  may  follow  ulceration  of  the  colon  apart  from  the 
presence  of  a  diverticulum — for  example,  a  stercoral,  tuberculous,  or 
malignant  ulcer,  or  an  ulcer  resulting  from  an  injury  produced  by  a 
foreign  body,  such  as  a  fish  or  game  bone. 

The  pathological  processes,  the  clinical  features,  and  the  general 
principles  of  treatment  are  the  same  as  those  of  allied  conditions 
resulting  from  appendicitis. 

TUBERCULOSIS    OF    THE    INTESTINE 
Tuberculosis  affects  the  intestine  in  two  distinct  ways  :    (1)  in  the 
form  of  multiple  ulcers,  and  (2)  by  the  formation  of  localized  tumour- 
like masses. 


Tuberculosis  of  intestine,  leading  to  multiple  strictures. 

{Museum,  Royal  College  of  Surgeons,  Edinburgh.-) 


PLATE   95- 


[NTESTINAL  TUBERCULOSIS 


,i  i 


1.  Ti  i.i  i;<  i  i, «Ms  Ulceration 

The  ulcerative  form  is  most    l'r.-« pi.ul ] \-  in«-1    with  IB   JTOUng  JUDJ 

wlio  Buffer  lioin  pulmonary  phthisis  or  from  some  other  tuberculous 

condition.  It  ohief 
gical  interesf  Lies  in  the 
l.i.t  thai  tlic  cicatricial 
contraction  which  accom- 
panies t  \\r  healing  <>\  rach 
ulcers  leads  i"  stenosis  "i 
the  bowel. 

The  Lower  end  of  the 
ileum  is  t  he  mosl  common 
seal  of  t  be  disease,  I  be  in- 
fection taking  place  from 
bacilli  thai  have  been 
swallowed  in  I  be  sputum, 
or  taken  in  with  milk  or 
other  food,  ami  bave  be- 
come implanted  in  the 
Peyer's  patches  ami  soli- 
tary glands.  As  the  foci 
break  down  and  cascate, 
they  form  small,  irregu- 
larly oval  ulcers  in  the 
mucous  membrane,  the 
edges  of  which  are  ele- 
vated (Fig.  423)  and  often 
indurated.  Such  ulcers 
tend  to  spread  circularly 
round  the  gut,  and,  as 
they  heal  at  one  part  while 
spreading  at  another,  the 
contraction  of  the  cica- 
tricial tissue  leads  to  ste- 
nosis of  the  bowel — one 
form  of  tuberculous  si  fu- 
ture (Plates  95,  96).  There 
may  be  several  si  rid  ores 
scattered  over  a  consider- 
able length  of  intestine,  the 
intervening  segments  being 
dilated  and  Bacculated  in 
a  characteristic  manner. 
Neighbouring    saccules 


;..  rly  stage  of 
u.cer  with 
raised  edges 


Ulcer  encircling 
the  bowel 


Perfuiation 


Fig.  423. 


-Tuberculous  ulceration  of 
the  intestine. 


(Museum,  Royal  College  of  Surgeons,   Edinburgh.) 


5i2  THE   INTESTINES 

are  liable  to  become  adherent  to  one  another  or  to  the  parietes,  and 
this  still  further  interferes  with  the  passage  of  the  intestinal  con- 
tents. The  peritoneal  covering  of  the  bowel  is  frequently  scattered 
over  with  miliary  tubercles,  and  the  associated  mesenteric  glands 
are  often  enlarged  and  caseous. 

The  usual  symptoms  associated  with  gradual  stenosis  of  the 
bowel  are  present — recurrent  attacks  of  abdominal  pain,  gradually 
increasing  distension  of  the  abdomen,  with  visible  peristalsis  and 
gurgling  intestinal  sounds.  One  or  more  tumour-like  masses  may 
be  felt  through  the  abdominal  wall  or  per  rectum. 

The  nature  of  the  lesion  can  usually  be  recognized  from  the  other 
evidence  of  tuberculosis,  by  the  von  Pirquet  test,  or  by  discovering 
tubercle  bacilli  in  the  fseces  ;  but  the  diagnosis  is  sometimes  only  made 
after  opening  the  abdomen. 

The  treatment  consists  in  resecting  the  affected  segment  of 
gut  when  this  is  practicable,  or  in  short-circuiting  the  bowel. 

The  other  complications  that  may  follow  on  tuberculous 
ulceration  of  the  intestine  are  perforations  (Fig.  423)  with  septic 
peritonitis  (but  this  is  rare  owing  to  the  thickening  of  the  peritoneal 
coat  and  the  formation  of  adhesions  outside  the  affected  segment 
of  bowel) ;  the  development  of  a  cold  abscess,  which,  on  bursting, 
may  establish  a  fistula  with  an  adjacent  hollow  viscus  or  with  the 
surface ;  and  general  tuberculous  peritonitis.  In  so  far  as  these 
conditions  are  amenable  to  surgical  treatment,  they  are  dealt  with 
on  the  same  lines  as  when  they  arise  from  other  causes. 

2.  Ileo-Cecal  Tuberculosis 

The  hyperplastic  or  hypertrophic  form  of  intestinal  tuberculosis 
is  almost  always  confined  to  the  csecum,  although  it  may  extend  for 
some  distance  in  the  ascending  colon,  and  frequently  in  the  terminal 
part  of  the  ileum.  Occasionally  the  proximal  part  of  the  appendix 
is  implicated. 

Morbid  anatomy. — This  affection  differs  from  other  mani- 
festations of  tuberculosis  in  that  the  lesion  is  not  a  destructive  one, 
but  is  attended  with  great  increase  in  the  bulk  of  the  csecum.  The 
disease  begins  in  the  submucous  or  subperitoneal  layers,  and  spreads 
to  other  coats  of  the  bowel,  which  become  diffusely  infiltrated  with 
small  round  cells  among  which  are  clumps  of  giant  cells  and  calcareous 
deposits,  and  the  wall  is  increased  in  thickness  and  rendered  rigid  by 
a  deposit  of  plastic  fibrous  tissue.  The  condition  tends  to  spread  by 
the  formation  of  fresh  zones  of  hyperplasia  in  the  distended  bowel 
above  the  level  of  the  primary  focus  (F.  M.  Caird).  The  thickened 
csecum  is  usually  included  in  a  mass  of  fibro-adipose  tissue  of  in- 
flammatory origin. 


Ileo-caecal  tuberculosis, 

{Authors  cast.) 


Plate  96. 


ii  i:o c  i:<:  \i    tuberculosis 


51: 


Contraction  of  the  mesocolon  drags  tin'  caecum  upwards  bo  thai 
it  may  lie  near  t  he  liver,  and  the  ileum  joins  11  a1  an  obtuse  angle. 
The  glands  in  the  mesentery  may  be  enlarged,  and  Eorm  a  solid  mass 
which  presses  upon  the  ,ufut  (Fig.  124). 

The  cavity  is  diminished  in  size,  and  the  lumen  pi  the  bowel  maj 
be  narrowed  down  to  a  track  no  larger  than  a  goose-quill.    Tin-  ileo- 


Fig.    424. — Tuberculous  mesenteric  glands  forming  a  solid  mass  which 
pressed  upon  the  bowel  and  caused  obstruction. 

(Museum,  Royal  College  of  Surgeons,   Edinburgh.) 

csecal  valve  is  shrivelled  up  and  often  cannot  be  recognized  (Plates 
95,  96). 

The  mucous  membrane  may  be  ulcerated  or  may  present  numerous 
villous  processes  projecting  like  polypi  from  its  surface.  These  vege- 
tations, which  spring  from  the  submucous  tissue,  have  the  structure 
of  ordinary  intestinal  adenomas,  and  they  vary  in  size  from  a  mere 
thread  to  a  hazel-nut. 

Clinical  features. — The  condition  is  usually  met  with  in 
patients  between  20  and  40  years  of  age,  who  show  slight,  if  any, 
1h 


5M  THK   INTESTINES 

evidence  of  pulmonary  disease.  It  may.  however,  occur  at  the  extremes 
of  life.  It  is  in.-idious  in  its  onset,  and  for  many  months  may  merely 
be  associated  with  some  loss  of  appetite  and  symptoms  of  indigestion, 
flight  occasional  discomfort  in  the  right  iliac  fossa,  and  the  passage 
of  blood  and  mucus.  As  time  goes  on,  the  patient  loses  strength 
and  emaciates,  and  he  suffers  from  frequent  attacks  of  griping  pain, 
coming  on  usually  two  or  three  hours  after  meals,  and  from  alternating 
ipation  and  diarrhoea.  In  some  cases  there  is  frequent  vomiting, 
which  affords  the  patient  relief.  There  may  be  localized  distension 
of  the  bowel,  with  loud  borborvgmi  and  visible  peristalsis,  the  intestine 
presenting  a  characteristic  ladder  pattern  (Fig.  406,  p.   472). 

Sooner  or  later,  a  palpable  swelling  can  be  detected  in  the  right 
loin,  the  lower  border  being  fairly  well  defined,  while  above  it  shades 
away  in  the  colon.  It  is  slightly  mobile  and  tender,  and  yields  an 
impaired  note  on  percussion. 

The  illness  may  culminate  in  an  attack  of  acute  obstruction. 
Abscesses  may  form,  and,  if  they  rupture  externally,  may  cause  per- 
sistent sinuses,  or  a  feecal  fistula.  Generalized  tuberculous  peritonitis 
is  a  rare  sequel. 

Diagnosis. — Compared  with  cancer,  with  which  it  is  most  liable 
to  be  confused,  the  progress  of  the  disease  is  slow,  and  there  is 
a  characteristic  intermission  in  the  symptoms,  which  may  last  for 
one  or  two  years  before  becoming  urgent.  In  some  cases  tuberculosis 
and  cancer  have  coexisted.  The  differential  diagnosis  from  chronic 
lesions  resulting  from  appendicitis  is  seldom  difficult.  It  is  impossible 
to  distinguish  clinically  between  ileo-caecal  tuberculosis  and  fibromatosis 
of  the  colon  affecting  the  eacal  region. 

Treatment. — The  treatment  consists  in  excising  the  caecum, 
and  establishing  a  lateral  anastomosis  on  the  same  lines  as  for  cancer, 
and  the  results  of  this  operation,  whether  performed  in  one  or  in  two 
stages,  have  proved  very  satisfactory. 

If  this  is  found  to  be  impossible,  an  anastomosis  may  be  effected 

between  the  small  intestine  and  the  colon  well  beyond  the  limits  of 

che  disease. 

ACTINOMYCOSIS 

The  caecum  is  by  far  the  most  common  seat  of  actinomycosis  in 
the  intestine,  but  the  pelvic  colon  also  is  sometimes  attacked. 

The  infection  takes  place  from  the  mucous  membrane  and  spreads 
through  the  various  coats  to  the  peritoneum,  and  thence  to  the  abdo- 
minal wall,  leading  to  the  formation  of  abscesses  and  sinuses.  In 
the  mucous  membrane  lining  the  sinuses,  or  in  the  pus  that  escapes 
from  them,  the  ray  fungus  may  be  found. 

Before  the  disease  infiltrates  the  parietes,  the  affected  segment  of 
bowel  becomes  greatly  thickened  and  adherent  to  adjacent  structures, 


FIBROMATOSIS   OF   THE   COLON  5*5 

ihf  whole  constituting  a  firm,  ill-defined,  diffuse  mass,  which  simulates 
malignant  disease  or  tuberculosis. 

The  treatment  consists  in  opening  np  the  Ednuses  and  removing 
the  infected  tissues  with  the  Bhaip  Bpoon  and  scissor-.  but  the  difficulty 
of  eradicating  the  whole  disease  renders  this  line  of  treatment  unsatis- 
factory. Equally  good  results  bave  been  claimed  foi  treatment  by 
large  doses  of  potassium  iodide  or  of  coppei  sulphate.  Irrigation  "l 
the  sinuses  with  a  1  per  cent,  solution  of  coppex  sulphate  bas  proved 
beneficial  (Bevan).     Injections  of  iodipin  are  also  of  value 

FIBROMATOSIS    OF   THE   COLON 

Under  this  name  may  be  described  a  condition  frequently  met  with 
in  the  colon  which  in  its  clinical  aspects  and  on  naked-eye  examination 
is  almost  indistinguishable  from  carcinoma  or  the  hyperplastic  form 
of  intestinal  tuberculosis. 

In  the  majority  of  cases  hitherto  reported  the  nature  of  the  con- 
dition has  only  been  recognized  after  the  growth  had  been  removed 
in  the  belief  that  it  was  a  malignant  tumour,  or  on  post-mortem 
examination.  The  microscopic  appearances,  however,  show  that  the 
mass  is  inflammatory  in  character,  and  presents  none  of  the  signs  of 
malignant  disease. 

It  is  highly  probable  that  many  of  the  cases  which  are  recorded 
of  malignant  disease  of  the  bowel  having  disappeared  after  colostomy 
or  short-circuiting  operations  performed  for  obstruction  were  of  this 
nature. 

Morbid  anatomy. — Any  part  of  the  colon  may  be  involved, 
but  the  condition  is  most  common  in  the  pelvic  colon  and  rectum. 
The  affected  segment  of  bowel,  varying  in  length  from  one  to  several 
inches,  is  converted  into  a  firm,  rigid  tube.  The  peritoneal  coat  is 
thick,  rough  and  granular,  and  may  show  signs  of  adhesive  inflam- 
mation. Beneath  the  serous  coat  is  a  uniform  layer  of  dense  fibro- 
adipose  tissue,  sometimes  half  an  inch  in  thickness.  The  muscular 
coat  may  show  some  degree  of  atrophy,  or  may  be  unaltered  in 
appearance. 

More  striking  changes  are  seen  in  the  submucous  layer,  which  is 
greatly  thickened  by  an  overgrowth  of  dense  fibrous  tissue.  This 
tends  to  contract,  and  in  so  doing  drags  upon  the  mucous  membrane, 
which  forms  a  series  of  irregular  folds  with  deep  recesses  between 
them  ;   these  are  sometimes  spoken  of  as  "  false  diverticula.  ' 

The  mucous  surface  may  thus  assume  a  festooned  or  cauliflower- 
like  appearance,  simulating  that  of  multiple  adenomas  or  papillomas. 
Ulcers  form  in  the  recesses  of  the  thickened  mucosa  and  burrow  under 
the  surface,  making  long,  undermined  tracts  with  overhanging  flaps 
of  mucous  membrane.     The  ulceration  may  extend  through  all  the 


5i6  THE   INTESTINES 

coats  of  the  bowel  and  lead  to  perforation.  In  some  eases,  the  mucous 
membrane  is  unaltered  in  appearance,  and  no  false  diverticula  arc 
present. 

The  lumen  of  the  bowel  is  usually  considerably  narrowed,  some- 
times to  such  an  extent  as  to  give  rise  to  symptoms  of  obstruction. 

On  microscopical  examination,  the  wall  of  the  bowel  is  infiltrated 
with  chronic  inflammatory  tissue,  and  there  is  an  overgrowth  of  the 
mucous  glands  with  aggregations  of  lymphoid  cells  between  them. 
The  epithelial  cells  of  the  glands  may  show  proliferation,  but  they  do 
not  extend  beyond  their  basement  membranes,  and  have  none  of  the 
appearances  of  carcinoma. 

Etiology. — These  changes  resemble  those  met  with  in  other 
organs  as  a  result  of  chronic  irritative  conditions,  and  in  all  probability 
are  due  to  infection  taking  place  through  some  lesion  of  the  mucosa — 
for  example,  an  abrasion  caused  by  a  foreign  body,  a  small  ulcer,  or 
the  lodgment  of  a  faecal  concretion  in  an  acquired  diverticulum, 
or  in  one  of  the  deeper  recesses  of  the  mucosa.  Cases  are  recorded 
in  which  the  infection  appeared  to  originate  in  other  organs,  such  as 
the  uterus  and  Fallopian  tubes,  with  which  the  colon  had  formed 
adhesions. 

Clinical  features. — This  condition  is  most  frequently  found 
in  patients  over  40  years  of  age,  but  it  occurs  also  in  younger  subjects. 
The  history  of  the  illness  is  very  like  that  of  malignant  disease  of  the 
colon.  There  is  generally  habitual  constipation,  with  periodic  attacks 
of  diarrhoea,  usually  induced  by  the  taking  of  a  strong  purgative,  the 
motions  often  containing  blood  and  mucus.  The  patient  complains 
of  persistent  abdominal  pain,  and  there  is  a  progressive  failure  of 
health.  When  the  disease  extends  into  the  rectum,  a  digital  examina- 
tion reveals  a  soft  condition  of  the  mucous  membrane,  which  has 
been  compared  to  thick  velvet  or  moss,  and  considerable  narrowing 
of  the  lumen.  With  the  sigmoidoscope  the  excessive  rugosity  and 
thickening  of  the  mucosa  can  be  seen. 

On  examination,  the  pelvic  colon  is  felt  to  stand  out  as  a  firm, 
sausage-shaped  swelling,  which  is  tender  on  pressure. 

A  positive  diagnosis  is  seldom  possible  without  an  exploratory 
operation. 

Treatment. — The  only  satisfactory  treatment  is  to  remove 
the  affected  segment  of  bowel.  If  there  are  symptoms  of  obstruction, 
or  if  the  patient  is  not  in  a  condition  for  such  an  operation,  colostomy 
should  be  performed  to  empty  the  bowel,  and  the  major  operation 
undertaken  at  a  later  date.  When  the  mass  is  considered  irremov- 
able, short-circuiting  should  be  performed  if  it  is  practicable.  In  a 
considerable  number  of  cases,  these  palliative  operations  have  been 
followed  by  diminution  or  even  disappearance  of  the  swelling. 


ULCERS   AFTER  GASTRO-ENTEROSTOMY        517 

ULCERATION   OF   THE    INTESTINE 

[t  is  important  to  distinguish  between  those  cases  in  which  ulceration 
is  an  accompaniment  or  complication  of  Buch  diseases  of  the  bowel  as 
tuberculosis,  malignant  disease,  and  chronic  obstruction  from  entero- 
liths or  fsecal  accumulation,  and  those  in  which  it   is  due  to  some 

specific  cause,  such  as  typhoid,  dysentery,  or  infection  with  particular 
organisms.  In  the  former  group,  the  symptoms  due  to  the  ulcer  are 
superadded  to,  and  cannot  be  distinguished  from,  those  of  the  primary 
lesion,  the  treatment  of  which  covers  the  treatment  of  the  ulcer.  In 
the  latter  group,  the  ulceration  itself  calls  for  treatment,  or  may  lead 
to  complications  which  bring  the  disease  within  the  province  of  the 
surgeon. 

Peptic  Ulcers  following  Gastro-Exterostomy  1 

In  a  small  proportion  of  cases  of  gastroenterostomy,  performed 
for  non-malignant  affections  of  the  stomach,  ulceration  occurs  at  the 
site  of  the  anastomosis — gastro- jejunal  ulcer  ;  or  in  the  jejunum  a  short 
distance  from  the  opening — jejunal  ulcer. 

The  chief  cause  of  the  gastro-jejunal  ulcer  seems  to  be  the  hyper- 
acidity of  the  stomach  contents,  although  "Wilkie  has  shown  experi- 
mentally that  this  alone  is  not  sufficient  to  produce  ulceration  in 
intact  mucous  membranes.  The  other  factors  are  the  presence  of 
a  ksematonia,  or  the  formation  of  granulation  tissue  at  the  site 
of  the  anastomosis,  which  usually  persists  for  about  a  week  after 
the  operation,  the  irritation  caused  by  unabsorbable  sutures  in  the 
granulating  area,  and  the  passage  of  solid  food  over  the  raw  surface 
during  the  healing  process. 

The  jejunal  ulcer  is  probably  due  to  the  action  of  the  acid  contents 
of  the  stomach  on  the  mucosa  of  the  jejunum,  which,  under  normal 
conditions,  is  exposed  to  an  alkaline  medium. 

The  fact  that  peptic  ulcers  almost  never  occur  after  gastro- 
enterostomy performed  for  cancer  of  the  stomach,  in  which  there  is 
a  deficiency  of  acid  in  the  contents,  supports  the  view  that  hyper- 
acidity is  an  important  factor  in  their  causation  in  non-malignant 
cases. 

The  prevention  of  these  ulcers  would  seem  to  depend  on  securing 
rapid  union  of  the  apposed  mucous  surfaces  by  accurate  suturing 
with  an  absorbable  material  such  as  catgut,  on  diminishing  the  acidity 
of  the  stomach  contents  or  securing  their  neutralization  by  the  bile 
and  pancreatic  secretions,  and  on  careful  dieting  to  diminish  mechanical 
irritation  of  the  healing  surfaces.  The  posterior  no-loop  operation 
of  gastroenterostomy  has  seldom  been  followed  by  ulceration. 

The  ulcer,  which  is  usually  single,  is  small  and  rounded,  and 
1  See  also  ante,  p.  414. 


5i8  THE    INTESTINES 

has  the  same  appearances  as  the  peptic  ulcer  of  the  stomach  or 
duodenum  (p.  344). 

The  presence  of  a  peptic  ulcer  should  be  suspected  when  symptoms 
similar  to  those  for  which  the  gastroenterostomy  was  performed  recur 
after  the  operation.  This  may  happen  within  a  few  days,  or  not  for 
many  months.  In  some  cases  perforation  lias  been  the  first  evidence 
of  the  presence  of  an  ulcer. 

Treatment. — If  medical  measures  fail,  and  if  the  hyperacidity 
persists,  it  may  be  necessary  to  enlarge  the  gastroenterostomy  opening, 
if  this  has  contracted  or  is  not  sufficiently  large,  or  to  perform  a  gastro- 
enterostomy by  the  Y-method,  implanting  the  proximal  limb  of  the  Y 
into  the  stomach,  so  that  the  bile  and  pancreatic  secretions  are  mixed 
with  the  gastric  juice  before  it  reaches  the  jejunum  (H.  J.  Paterson). 

Typhoid  Perforation 

It  has  been  estimated  that  perforation  of  an  ulcer  occurs  in  about 
2J  to  3  per  cent,  of  cases  of  typhoid  fever.  This  complication  usually 
arises  during  the  second  or  third  week  of  the  fever,  in  patients  who 
are  under  treatment  for  a  severe  attack,  but  it  may  be  delayed  until 
the  patient  is  in  the  convalescent  stage,  or  it  may  even  occur  in  mild 
and  "  ambulant  "  cases  and  be  the  first  manifestation  of  the  disease. 

The  ulcer  which  perforates  is  usually  situated  in  the  lower  end  of 
the  ileum,  within  2  or  3  ft.  of  the  ileo-csecal  junction.  Occasionally 
more  than  one  ulcer  perforates. 

The  opening  may  be  no  larger  than  a  pin's  head,  and  is  only  dis- 
covered when  some  flaky  lymph  is  removed  from  the  serous  covering 
of  the  bowel.  When  sloughing  of  the  wall  of  the  gut  has  taken  place, 
the  opening  may  be  of  considerable  size.  It  is  usually  on  the  convex 
side  of  the  bowel,   where  the  blood  supply  is  least. 

Clinical  features.- — Perforation  is  most  frequently  met  with 
in  young  adult  males,  but  it  may  occur  at  all  ages,  and  in  both 
sexes.  In  patients  who  are  seriously  ill  with  general  symptoms  of 
typhoid  fever  the  diagnosis  of  perforation  is  often  extremely  difficult, 
but  if  there  are  reasonable  grounds  for  suspecting  that  the  bowel  has 
given  way,  an  exploratory  incision  should  at  once  be  made.  Experi- 
ence abundantly  proves  that  success  largely  depends  on  the  shortness 
of  the  interval  between  the  occurrence  of  perforation  and  the  opera- 
tion for  its  closure. 

The  symptoms  that  suggest  perforation  are  the  sudden  onset  of 
acute  pain  referred  to  the  umbilicus  or  to  the  right  lower  half  of  the 
abdomen,  with  tenderness  on  pressure,  and  muscular  rigidity,  most 
marked  in  the  right  lower  quadrant  of  the  abdomen.  There  is  nausea 
and  vomiting,  and  other  symptoms  of  acute  infective  peritonitis  soon 
supervene. 


ULCERATION 

Treatment.  The  abdomen  is  opened  in  the  middle  line  below 
the  umbilicus,  or  in  the  right  semilunar  line,  and  ii  the  patient's  con- 
dition forbids  the  administration  <>f  .1  genera]  anaesthetic,  tin-  operation 
ran  be  done  under  local  anaesthesia.  The  caecum  is  first  identified 
and  examined,  and  thru  the  lower  coils  of  the  drum.  The  perforation 
may  only  be  revealed  by  removing  adherent  flakes  of  lymph,  and. 
when  it  is  found,  it  is  closed  by  Lembert  sutures  and  sealed  l>\-  an 
omenta]  graft. 

As  multiple  perforations  are  not  uncommon,  a  thorough  search 
should  be  made,  mid  any  suspicious  area  should  bo  invaginated  with 
a  purse-String  suture,   and  covered   with   an   omental   graft. 

When  there  is  a  patch  of  gangrene  on  the  bowel,  and  the  patient 
cannot  tolerate  immediate  resection,  the  affected  loop  should  be  brought 
to  the  surface,  and  an  artificial  anus  established. 

Cases  have  been  recorded  in  which  a  second  perforation  occurred 
after  the  patient  had  recovered  from  an  operation,  and  a  second 
laparotomy  was  called  for. 

Dysenteric  Ulceration 

For  a  description  of  dysentery,  the  reader  is  referred  to  works  on 
Medicine.  Suffice  it  here  to  say  that  in  the  course  of  the  dise 
extensive  ulceration  frequently  occurs  in  the  colon,  particularly  in 
the  pelvic  and  descending  portions.  The  typical  dysenteric  ulcer 
begins  as  a  small  yellow  or  grey  erosion  at  the  opening  of  one  of  the 
glands  of  the  mucosa,  and  gradually  spreads  in  the  submucous  layer, 
undermining  the  mucosa  and  eating  into  the  muscular  coat.  The 
affected  segment  of  bowel  is  studded  over  with  such  ulcers,  which  as 
they  spread  coalesce  ind  may  eventually  cover  a  large  area.  The 
irritation  causes  the  peritoneal  coat  to  swell  and  form  adhesions  with 
surrounding  structures,  particularly  with  the  omentum,  which  serves 
to  prevent  a  generalized  infection  of  the  peritoneal  cavity  when  per- 
foration occurs,  as  it  frequently  does.  Localized  suppuration  in  the 
subperitoneal  or  in  the  extraperitoneal  tissue  is  not  uncommon. 
Abscess  of  the  liver  is  also  a  frequent  complication.  The  contraction 
which  occurs  in  the  healing  of  these  extensive  ulcers  often  leads  to 
considerable    stenosis    of    the    bowel — dysenteric    strict  int. 

Treatment. — When  the  disease  does  not  yield  to  medical 
measures,  surgical  interference  is  indicated  to  secure  rest  for  the  col 
and  to  admit  of  the  direct  application  of  remedial  agents  to  the  inflamed 
and  ulcerated  mucous  membrane.  This  is  best  effected  by  performing 
appendicostomy.  The  fluids  most  frequently  employed  for  irrigation 
are  saline  solution  and  weak  solutions  of  the  albuminous  silver  salts, 
such  as  protargol  or  argvrol,  from  4  to  S  pints  being  used  three  times 
a  .day. 


52o  THE   INTESTINES 

If  it  is  necessary  to  divert  the  fasces  from  the  colon  entirely,  an 
artificial  anus  is  made  in  the  first  part  of  the  ascending  colon,  and 
through  this  irrigation  can  be  carried  out.  The  artificial  anus  is 
closed  when  the  disease  has  been  overcome. 

When  it  is  possible  to  implant  the  lower  end  of  the  divided  ileum 
into  the  pelvic  colon  (ileo-sigmoidostomy)  beyond  the  ulcerated  area, 
this  operation   is   preferable  to  the   formation  of   an   artificial  anus. 

Ulcerative  Colitis 

Under  this  term  are  included  certain  forms  of  ulceration  of  the 
colon  which  cannot  be  ascribed  to  any  specific  organism  or  irritant, 
although  they  are  closely  allied  to  dysenteric  ulceration. 

The  ulcers,  which  may  be  met  with  at  various  stages,  vary  greatly 
in  size,  some  being  no  larger  than  a  pea,  while  others  destroy  large 
tracts  of  the  mucosa.  The  edges  are  raised  and  irregular,  the  base 
is  covered  with  feeble  granulations  to  which  shreds  of  tenacious  mucus 
adhere,  and  the  surrounding  mucous  membrane  is  inflamed  and  red. 
The  mucosa  between  the  ulcers  is  cedematous  and  raised,  so  that  it 
may  assume  the  appearance  of  a  series  of  polypi.  The  destructive 
process  gradually  spreads  through  the  coats  of  the  bowel,  and  may 
end  in  perforation,  and  set  up  a  localized  pericolitis  or  peritonitis. 
If  a  large  artery  is  involved,  copious  hemorrhage  may  result.  Abscess 
of  the  Liver  is  a  rare  complication  of  this  type  of  ulceration — a  point 
in  which  it  differs  from  the  dysenteric  form. 

Clinical  features. — The  disease  is  commonest  in  early  adult 
life  and  affects  the  sexes  equally.  The  outstanding  symptom  is 
diarrhoea  attended  with  abdominal  pain  and  tenderness  along  the 
line  of  the  colon. 

The  bowels  move  very  frequently,  sometimes  every  two  or  three 
hours  ;  there  is  seldom  tenesmus  unless  the  rectum  also  is  implicated. 
The  motions  are  watery  and  contain  only  a  small  proportion  of 
feculent  matter,  but  a  great  quantity  of  mucus,  some  pus,  and  often 
blood.     The  dejections  are  very  offensive. 

As  the  food  passes  through  the  bowel  quickly  and  is  imperfectly 
digested,  the  patient  emaciates  rapidly.  The  disease  is  a  very  intract- 
able one,  and  is  attended  with  a  high  mortality.. 

By  the  use  of  the  sigmoidoscope,  the  ulcers  in  the  pelvic  colon  may 
be  seen. 

Some  cases  run  a  less  acute  course,  the  symptoms  disappearing 
and  recurring  at  intervals. 

Treatment. — General  dietetic  and  medicinal  treatment,  carried 
out  on  the  same  fines  as  for  other  forms  of  inflammation  and  ulceration 
of  the  colon,  should  be  tried  in  the  first  instance.  The  use  of  a  bacillus 
coli  vaccine  has  proved  beneficial  (Hale  White).     If  these  measures 


STERCORAL    ULCERS 


are  not  speedily  followed  by  improvement,  appendicostomy  Bhould 
be  performed  to  enable  the  colon  to  If  irrigated  with  saline  solution 
or  solutions  of  the  silver  salts.     When  the  lesions  are  confined  to  the 

lower  part  of  the  colon,  Local  applications  may  I mployed  with  the 

aid  oi  the  sigmoidoscope. 


Fig.  425. — Stercoral  ulcers  of  colon. 

(Museum,  Royal  College  of  Surgeons,  Edinburgh.') 


Stercoral  Ulcers 

The  pressure  of  a  hardened  mass  of  faeces  or  an  enterolith  on  the 
mucous  membrane  may  give  rise  to  ulceration — stercoral  ulcers — the 
mucosa  being  eroded  in  patches  (Fig.  425). 

Such  ulcers  are  most  frequently  met  with  in  the  rectum,  the  pelvic 
colon,  and  the  csecum,  and  they  exude  a  blood-stained,  muco-purulent 


522  THE    INTESTINES 

discharge,  which  escapes  with  some  fluid  faecal  matter,  giving  rise  to 
what  is  often  misleadingly  described  by  the  patient  as  diarrhoea. 
Absorption  of  toxins  takes  place  from  the  eroded  surfaces,  causing  a 
variable  degree  of  auto-intoxication.  The  ulcerative  process  may 
spread  to  the  muscular  and  serous  coats,  and  give  rise  to  pericolitis 
and  localized  abscess,  or  perforation  may  occur  and  set  up  peritonitis. 

STRICTURE   OR   STENOSIS 

Narrowing  of  the  lumen  of  the  bowel  is  an  incidental  accompani- 
ment of  nearly  all  morbid  conditions  affecting  the  intestine,  and  on  this 
factor  many  of  the  most  troublesome  symptoms  and  some  of  the  most 
serious  risks  ultimately  depend.  In  such  diseases  as  carcinoma,  the 
hypertrophic  form  of  tuberculosis,  actinomycosis,  and  fibromatosis 
of  the  colon,  progressive  organic  stenosis  is  an  almost  constant  result, 
but  as  this  does  not  constitute  the  essential  feature  of  these  affections, 
it  seems  unnecessary  and  undesirable  to  differentiate  and  describe  as 
separate  conditions  malignant,  tuberculous,  and  other  forms  of 
stricture.  The  symptoms  referable  to  the  stenosis  are  more  properly 
included  with  the  other  clinical  features  of  each  disease. 

Stenosis  resulting  from  the  contraction  of  cicatricial  tissue  in  or 
around  the  wall  of  the  gut,  however,  requires  special  mention. 

Cicatricial  Stricture  or  Stenosis 

The  formation  of  cicatricial  tissue  in  the  wall  of  the  bowel  during 
the  repair  of  destructive  lesions  is  attended  with  a  variable  amount 
of  narrowing  of  the  lumen,  but  the  stenosis  rarely  proceeds  to  such 
an  extent  as  to  cause  complete  obstruction. 

The  interference  with  the  passage  of  the  intestinal  contents, 
however,  is  liable  to  be  aggravated  from  time  to  time  as  a  result  of 
temporary  congestion  of  the  mucous  membrane,  or  spasm  of  the 
circular  muscular  fibres.  If  to  this  is  added  a  kinking  or  torsion 
of  the  affected  loop,  the  lumen  may  be  entirely  occluded  and  acute 
symptoms  suddenly  supervene. 

The  most  common  cause  of  cicatricial  stenosis  is  the  healing  of  a 
tuberculous  ulcer  (p.  511).  Syphilitic,  typhoid,  or  dysenteric  ulceration 
rarely  gives  rise  to  a  sufficient  degree  of  cicatricial  contraction  to  cause 
symptoms  of  stenosis,  and  narrowing  of  the  bowel  seldom  follows  the 
reduction  of  an  intussusception. 

The  two  forms  that  call  for  special  mention  here  are  those  that 
result  from  direct  injury  of  the  bowel,  and  from  the  effects  of  a  tem- 
porary strangulation,  as  in  hernia. 

Traumatic  stricture. — It  occasionally  happens  that  the  process  of 
repair  in  a  portion  of  bowel  which  has  been  contused  or  ruptured  by 
external  violence,  such  as  a  kick  or  a  blow,  subsequently  results  in 


CICATRICIAL   STRICTURE 

narrowing  >>i  the  tube.  Similarly,  the  cicatrix  produced  after  closing 
;i  perforation  of  the  gu1  l>\  .1  purse-string  or  Lemberl  suture,  or  thai 
resulting  after  resection  or  lateral  anastomosis,  may  undergo  such 
contraction  as  to  lead  to  Btenosis.  This  appears  to  be  more  common 
when  mechanical  means,  such  as  a  Murphy's  button  or  a  bone  bobbin, 
have  been  employed. 

The  symptoms  of  stenosis  usually  ensue  Erom  one  to  Eour  months 
after  the  accident,  bul  I  bad  one  case  in  which  more  than  a  pear 
elapsed  before  acute  obstruction  followed  the  invagination  of  a  numbei 

of  punctures   of   the   small    intestine   produced    by   an    iron   spike. 

The  affected  segmenl  of  bowel  lias  usually  formed  adhesions  with 
the  omentum,  the  parietal  peritoneum,  <>r  adjacent  coils  of  intestine, 
which  favour  the  occurrence  of  kinking  or  bending,  and  so  increase 
the  liability  to  obstruction. 

Stricture  after  strangulated  hernia. — This  is  a  comparatively  rare 
sequel  of  strangulated  hernia,  and  it  almost  always  affects  the  small 
intestine. 

It  may  follow  reduction  by  taxis  or  by  operation.  The  stricture 
forms  at  the  site  of  the  constriction  groove  ;  sometimes  there  is 
narrowing  at  each  end  of  the  strangulated  loop.  As  a  rule,  it  is  annular 
and  so  limited  as  to  give  the  appearance  of  a  string  tied  round  the 
bowel ;  occasionally  an  inch  or  more  of  the  bowel  is  stenosed.  In 
a  case  of  strangulated  obturator  hernia  operated  on  by  me,  in 
which  the  constriction  groove  was  invaginated  by  a  double  Lembert 
suture,  a  diaphragm  formed  which  in  the  course  of  four  months  had 
completely  occluded  the  bowel  (Fig.  426).  Perforation  occurred  above 
this  diaphragm.  Recovery  followed  resection  of  the  affected  segment 
with  lateral  anastomosis. 

Clinical  features  of  cicatricial  stricture. — The  symp- 
toms are  those  common  to  all  forms  of  increasing  stenosis  of  the 
bowel  (p.  471).  The  history  of  a  previous  injury  or  operation,  of  ? 
strangulated  hernia  reduced  by  taxis  or  otherwise,  or  of  tuberculous 
disease  of  the  bowel  suggests  this  possibility. 

In  the  small  intestine  and  upper  colon,  where  the  contents  of  the 
bowel  are  normally  liquid,  a  very  considerable  degree  of  narrowing 
may  be  present  before  signs  of  obstruction  manifest  themselves,  while 
in  the  lower  colon,  where  the  contents  are  solid,  a  moderate  degree  of 
stenosis  will  cause  symptoms. 

Marked  variability  in  the  severity  of  the  symptoms,  due  to  periodic 
attacks  of  congestion  or  spasm,  is  suggestive  of  cicatricial  stenosis. 

It  is  often  impossible  to  arrive  at  an  accurate  diagnosis  until  the 
abdomen  is  opened. 

Treatment. — Before  the  onset  of  acute  obstruction,  the  ideal 
method   of   treatment    is    resection    of    the    affected    loop    of    bowel. 


5-4 


THE   INTESTINES 


with  closure  of  the  divided  ends,  and  restoration  of  the  continuity 
of  the  (.anal  by  lateral  anastomosis.  If  this  is  impracticable,  the 
stenosed  segment  may  be  excluded  by  short-circuiting  the  bowel. 
The  degree  of  narrowing  is  seldom  so  slight  as  to  warrant  a  simple 
enteroplasty. 

When  symptoms  of  acute  obstruction  are  present,  a  temporary 


Perforation  above 
diaphragm 
Diaphragm 

Fig.  426. — Stenosis  of  small  intestine  due  to  formation  of  a  diaphragm 
at  the  seat  of  suture  after  strangulated  hernia. 

{Author's  case.) 

artificial  anus  should  be  established,  and,  after  the  bowel  has  been 
emptied,  the  stenosed  portion  may  be  dealt  with  by  excision  or  short- 
circuiting  according  to  circumstances. 


TUMOURS 
TUMOURS    OF   THE   SMALL   INTESTINE 

The   small  intestine  is   seldom  the  seat  of  new   growths,   either 
innocent  or  malignant. 


TUMOURS  OF   THE   SMALL    INTESTINE  525 

[nnocent  Tumoi  Eta 

Of  the  innocenl  tumours  tnel  with,  perhapa  the  most  common 
are  adenomas,  which  arise  in  Lieberkuhn's  follicles  and  form 
pedunculated  growths  projecting  into  the  Lumen  ol  the  bowel.  They 
may  be  solitary,  or  may  be  found  scattered  throughoul  the  whole 
length  of  the  mi  est  inc.     They  show  Less  tendency  to  become  malignanl 

than  similar  tumours  situated  in  the  colon. 

Fibromas  and  lipomas  usually  arise  in  the  submueosa,  and. 
becoming  pedunculated,  project  into  the  bowel.  They  ai''  almosl 
always  met  with  in  the  lower  part  of  the  ileum.1 

Myomas  originate  in  the  muscular  coat,  and  also  tend  in  become 
pedunculated. 

Angiomas  are  so  rare  that  their  occurrence  lias  been  denied. 

Innocent  tumours  of  the  small  intestine  seldom  give  rise  to  trouble, 
unless  they  increase  to  such  a  size  as  to  obstruct  the  lumen  of  the  gut, 
or  by  dragging  upon  the  wall  of  the  bowel  induce  an  intussusception. 
In  either  case,  the  symptoms  are  those  of  intestinal  obstruction,  and 
the  presence  of  the  tumour  is  only  discovered  after  opening  the 
abdomen. 

Malignant  Tumours 

Malignant  tumours  are  much  less  common  in  the  small  intestine 
than  in  the  colon. 

Carcinoma.2 — Not  more  than  5  per  cent,  of  carcinomas  of  the 
bowel  affect  the  small  intestine,  and  of  these  the  great  majority  are 
found  in  the  lower  part  of  the  ileum.  The  tumour  is  almost  always 
of  the  columnar-celled  variety,  and  tends  to  grow  round  the  bowel, 
gradually  narrowing  the,  lumen.  As  the  contents  of  the  small  intestine 
are  fluid,  the  constriction  of  the  bowel  may  progress  till  the  lumen 
is  reduced  to  the  size  of  a  crow-quill  before  signs  of  obstruction  develop. 

The  exposed  surface  of  the  growth  may  ulcerate,  and  the  changes 
characteristic  of  gradually  increasing  obstruction  are  evident  in  the 
bowel  above  and  below  the  tumour.  Secondary  deposits  are  occasion- 
ally found  in  other  parts  of  the  bowel,  but  these  seldom  give  rise  to 
obstruction. 

Clinical  features. — The  symptoms  of  cancer  of  the  small  intestine 
are  less  characteristic  than  those  of  cancer  of  the  colon.  Vomiting 
and  pain  are  more  severe  and  persistent,  and  the  pain  often  fol- 
lows the  talcing  of  food.  The  distended  coils  are  centrally  placed. 
and  tend  to  assume  a  "ladder  pattern,"  and  strong,  rapid  peristaltic 
waves  may  be  seen  passing  along  them  from  time  to  time.  Unless, 
however,  a  palpable  swelling  can  be  recognized,  it  is  seldom  possible 
to  affirm  more  than  that  some  form  of  stenosis  is  present. 

1  See  Vol.  L,  p.  379.  2  See  Vol.  I.,  p.  550. 


526  THE   INTESTINES 

Treatment. — When  a  positive  diagnosis  is  impossible,  and  the 
symptoms  of  stenosis  are  progressive,  the  abdomen  should  be  opened, 
and  tlic  cause  sought  for.  If  it  is  found  to  be  a  malignant  growth 
of  the  small  intestine,  the  affected  segment  should  be  excised,  and  a 
lateral  anastomosis  established. 

Sarcoma.1 — Sarcoma,  although  rare  in  the  small  intestine,  is 
less  infrequent  there  than  in  the  colon. 

The  growth  arises  in  the  submucosa,  and  may  project  towards 
the  lumen  as  a  pedunculated  tumour  of  the  spindle-celled  or  round- 
celled  variety,  and  may  infiltrate  the  coats  of  the  bowel,  forming  a 
localized  thickening  which  encircles  the  tube,  without,  however, 
narrowing  it.  Indeed,  the  lumen  is  sometimes  widened  at  first.  In 
course  of  time  the  growth  may  encroach  upon  the  lumen  and  cause 
stenosis,  but  this  is  a  late  development,  as  is  also  involvement  of  the 
serous  coat. 

Multiple  growths  sometimes  occur.  The  lymphatics  of  the 
mesentery  and  omentum  are  soon  infected,  and  metastasis  to  the 
liver  and  kidney  occurs  early. 

Clinical  features. — The  disease  is  one  of  early  fife,  sometimes 
occurring  in  infants.  The  symptoms  are  usually  vague  and  are  con- 
stitutional rather  than  local — progressive  emaciation,  loss  of  appetite, 
and  great  weakness.  Eventually  there  may  be  irregularity  of  the 
bowels,  with  alternating  constipation  and  diarrhoea,  and  vague 
abdominal  pains.  Sooner  or  later  a  palpable  tumour  is  recognizable, 
and  this  rapidly  increases  in  size. 

The  treatment  is  carried  out  on  the  same  lines  as  for  carcinoma, 
but  if  excision  is  to  be  successful  it  must  be  performed  early. 

TUMOURS    OF   THE   COLON 
Innocent  Tumours 

The  same  varieties  of  innocent  tumours  are  met  with  in  the  colon 
as  in  the  small  intestine  (p.  525),  and  they  present  very  much  the  same 
appearances  and  give  rise  to  the  same  symptoms. 

The  only  form  that  requires  special  mention  is  the  multiple 
adenomas,2  first  described  by  Virchow  in  1863.  These  tumours 
may  be  present  in  enormous  numbers,  some  small,  flat,  and  sessile, 
others  pedunculated  and  reaching  the  size  of  a  cherry  or  even  of  a 
walnut.  They  are  most  numerous  in  the  pelvic  and  descending 
portions  of  the  colon,  and  as  a  rule  extend  into  the  rectum. 

While  originally  composed  of  true  adenomatous  tissue  with  a 
covering  of  columnar  epithelium  derived  from  the  mucous  membrane, 
they  show  a  marked  tendency  to  become  malignant,  particularly  when 

1  See  Vol.  I.,  p.  505.  8  See  Vol.  I.,  p.  437. 


TIMOIKS    o|      I  Ml     COLON  527 

they  ulcerate,  aa  they  frequently  <1<>  in  the  lower  parte  oi  the  bowel, 
where  they  are  subjected  to  irritation  by  hard  h 

These  growths  are  to  be  clearly  distinguished  from  the  polypoid 

condition  <>f  the  mucous  membrane  frequently  me1   with  in  cases  "t 
ileo-csecal  tuberculosis,  Btricture  <>|'  the  bowel,  and  fibromatosis  of  the 

colon. 

Clinical  features. — The  most  characteristic  feature  i-  severe 
and  intractable  diarrhoea,  frequently  attended  with  painful  tenesmus. 
The  stools  contain  a  great  quantity  of  mucus,  which  is  often  mixed 
with  blood.  There  is  constant  pain  in  the  abdomen  and  tender] 
on  pressure  alone;  the  line  of  the  colon,  and  the  patient  becomes  anaemic 
and  rapidly  emaciates.  The  tumours  may  be  felt  on  digital  examina- 
tion of  the  rectum,  or  they  may  be  seen  with  the  aid  of  the  sigmoidoscope. 

Treatment. — The  only  treatment  that  holds  out  any  hope  of 
complete  or  permanent  relief  is  excision  of  the  whole  colon,  but 
the  growths  frequently  invade  the  rectum  also,  this  is  not  always 
practicable.  The  risk  of  the  operation  in  suitable  cases  is  compensated 
for  by  the  prospect  of  getting  rid  of  a  condition  which  is  likely  sooner 
or  later  to  assume  malignant  characters. 

No  extensive  operation  should  be  undertaken  to  remove  the  growths 
found  in  the  rectum  until  it  has  been  determined  that  the  colon  is 
free  of  them,  as  no  benefit  follows  this  procedure.  Nor  does  colostomy 
with  irrigation  of  the  colon  afford  such  relief  as  to  compensate  for  the 
discomfort  of  the  artificial  anus. 

Malignant  Tumours 

Carcinoma.1 — If  we  exclude  the  rectum,  it  may  be  said  that 
95  per  cent,  of  cases  of  carcinoma  of  the  intestine  are  met  with  in 
the  colon.  The  tumour  in  the  colon  is  nearly  always  the  primary 
lesion,  growths  of  metastatic  origin  being  rare.  I  have  met  with  one 
case  in  which  cancer  of  the  colon  supervened  in  a  patient  whose 
breast  I  had  removed  for  scirrhous  carcinoma  some  years  pre- 
viously. Cases  have  been  recorded  in  which  more  than  one  tumour 
was  present  in  the  bowel,  probably  as  a  result  of  direct  infection  by 
implantation,  but  cancers  of  different  varieties  may  also  be  present 
in  the  same  case. 

As  compared  with  cancer  in  other  parts  of  the  body,  carcinoma 
of  the  colon  is.  on  the  whole,  less  malignant,  the  growth  of  the  tumour 
being  slower,  the  invasion  of  lymphatics  taking  place  later,  and  metas- 
tasis occurring  only  at  a  late  stage  in  the  disease.  It  is  not  on  this 
account,  however,  less  serious,  as  the  effect  of  the  tumour  in  occluding 
the  lumen  of  the  gut  and  leading  to  obstruction  of  the  bowels  renders 
it  a  condition  of  great  gravity. 

§      Vol.  I.,  p.  551. 


528 


THE   INTESTINES 


Morbid  anatomy. — The  commonest  variety  is  the  columnar 
epithelioma,  or  adeno-eareinonia,  originating  in  the  glands  of  Licber- 
kiihn.     The  tumour  may  form  a  cauliiiower-like  growth  which  projects 


Ileo-caecal  valve. 


i  Lc  gland 


Fig.  427. — Cancer  of  ascending  colon  filling  lumen  of  bowel. 

{Museum,  Royal  College  of  Surgeons,  Edinburgh.) 

into  the  lumen  of  the  bowel,  and  soon  ulcerates  on  the  surface  (Figs. 
427,  428) ;  or  it  may  assume  the  scirrhous  type,  slowly  encircling  the 
bowel,  and  producing  an  annular  stricture,  sometimes  so  limited  in 
extent  as  to  give  the  appearance  of  a  string  tied  tightly  round  the 


CARCINOMA   OF   THE  COLON 


5*9 


bowel  (Fig.  429).  En  this  form  the  lumen  of  the  bowel  may  be 
almost  completely  occluded  before  the  growth  oloerates.  Colloid  oi 
encephaloid  degeneration  may  occur  in  either  form. 

On  mesial  Longitudinal  Bection,  the  lumen  of  the  bowel  is  found 
contracted,  il    may  be  to  the  size  of  a  crow-quill,  by  e   well-defined 
ridge    or  ring 
representing  the 
oldest,  c  <•  n  t  ral 
portion    of    the 
growth,    while 
above  and  below 
this    the   cancer 
extends    in    the 
mucous      mem- 
brane for  about 
an  inch  in  each 
direction      (Fig. 
430).   The  bowel 
above      is      dis- 
tended,   and   its 
wall     undergoes 
a     moderate 
amount    of    hy- 
pertrophy.    The 
mucous      mem- 
brane   is    in    a 
condition  of  ca- 
tarrh   and    may 
become       ulcer- 
ated. 

The  disease 
slowly  spreads 
to  the  glands  of 
the  mesocolon, 
and  also  to  the 
retroperitoneal 
glands,  and  when 

secondary  deposits  occur  they  almost  always  appear  first  m  the  liver. 
Secondary  growths  are  not  infrequent  in  the  omentum,  mesenteries, 
and  peritoneum,  and  I  have  met  with  one  case  in  winch  both 
ovaries  were  also  the  seat  of  secondary  deposits.  These  are  usually 
attended  with  a  considerable  amount  of  ascites.  Spread  by  continuity 
to  adjacent  viscera,  such  as  the  stomach,  the  bladder,  the  female  pelvic 
organs,  and  to  neighbouring  coils  of  small  intestine,  is  not  uncommon. 


'"->' 


W 


Fig.  428. — Cancer  of  colon   forming   cauliflower-like 
growth  projecting  into  lumen  of  bowel. 

{Museum,  Royal  College  of  Surgeons,   Edinburgh.) 


530 


THK    INTESTINKS 


Cicatricial  contraction  of  the  mesocolon  may  fix  the  tumour 
and  bind  it  to  the  parietes,  and  this  in  turn  may  lead  to  kinking 
or  bending  of  the  bowel  and  cause  obstruction. 


Fig.   429. — Annular    stricture    of 
bowel  due  to  scirrhous  cancer. 


I  This  and  the  next  figure  are  from  specimens 
in  the  Museum  of  the  Royal  College  <y 
Surgeons.  Edinburgh.) 


Fig.  430.-  Mesial  longitudinal  sec- 
tion of  same  specimen  as  Fig. 
429,  to  show  occlusion  of  lumen 
by  scirrhous  cancer.  Note  hy- 
pertrophy of  muscular  coat 
above  stricture. 


Cancer  of  the  caecum  is  liable  to  imphcate  the  parietes,  and  in  the 
retroperitoneal  tissue  cellulitis  and  abscess  formation  may  occur,  giving 
rise  to  symptoms  which  simulate  appendicitis.  The  bursting  of  an 
abscess  on  the  surface  may  establish  a  f fecal  fistula. 


CARCINOMA   OF   THE   col. ON 

Sites.-  The  pelvic  colon  is  the  mosl  common  seal  of  carcinoma, 
.Hid  next  in  oidei  <>f  frequency  come  the  csecum  and  the  ascendii 
colon,  the  transverse  colon  and  splenic  flexure,  and  Lastly  the  hepatic 
flexure  and  descending  colon. 

Carcinoma  of  the  pelvic  colon  sometimes  originates  in  the  cicatrix 
of  a  stercoral  ulcer. 

Clinical  features.      Before  the  onset   of  complete   obstruction. — <\ 
The  extent  to  which   the   colon   may  be  narrowed  by  a   malignant 
stricture,  without  giving  list-  to  any  Bymptoms,  is  often  remarkable, 
and  in  many  cases  attention  is  firsl  directed  to  the  condition  by  the 
onset  of  the  symptoms  of  acute  obstruction. 

When  the  tumour  manifests  itself  in  its  early  stages,  the  symptoms*^ 
are  usually  those  ._^jyvjr-iti,m  Mf  t)lf_  hn«-pl  and  are  common  to  manyv 
other  conditions  than  cancer.  It  may  be  noticed  that  the  patient  is 
losing  strength,  is  depressed  and  listless,  and  complains  of  vague 
abdominal  discomfort,  rarely  amounting  to  pain.  Loss  of  weight  is 
not  a  prominent  feature  in  the  early  stages  ;  in  fact,  the  patient  may 
even  be  putting  on  weight.  There  is  a  gradually  increasing  difficulty 
in  keeping  the  bowels  regular,  necessitating  the  frequent  use  of  pur- 
gatives. The  constipation  gradually  becomes  more  pronounced,  and 
the  medicines  that  previously  procured  a  motion  merely  Induce  attacks 
of  colicky  pain  and  flatulent  distension.  Soon  the  patient  begin- 
to  suffer  from  recurrent  attacks  of  spurious  diarrhoea,  passing  a  small 
quantity  of  fasces,  with  a  good  deal  of  mucus  and  some  flatus.  This 
does  not  give  him  relief,  and  is  usually  followed  by  a  further  period  of 
constipation.  The  sequence  of  alternating  constipation  and  diarrhoea 
is  very  characteristic  of  cancer  of  the  colon,  and  should  always  lead 
to  a  systematic  examination  of  the  abdomen.  On  examination,  the 
-tools  are  found  to  contain  a  small  quantity  of  blood,  sometimes  only 
detectable  by  the  microscope,  or  by  the  guaiac  or  the  benzidine  tet 
There  is  seldom  a  large  haemorrhage  from  the  bowel,.  Xo  importance 
is  to  be  attached  to  the  shape  of  the  motions,  unless  the  cancer  actually 
implicates  the  anal  canal. 

Vomiting  is  seldom  a   constant   or  prominent   symptom ;    when 
it  occurs,  it  is  usually  in  relation  with  the  taking  of  food. 

It  is  not  always  possible  to  detect  a  localized  swelling  in  the 
abdomen,  as,  even  when  of  considerable  size,  the  growth  may  be 
obscured  by  the  thickness  of  the  abdominal  wall,  or  by  flatulent  dis- 
tension. When  situated  in  the  splenic  or  hepatic  flexure  it  lies  under 
cover  of  the  ribs.  When  palpable,  the  tumour,  although  solid  to 
the  feel,  is  usually  resonant  on  percussion,  and  it  is  not  alw 
tender.     Frequently  the  swelling  that  is  felt  is  due  cumula- 

tion of  faeces   above    a  stricture,  in   which  case  it   is  comparatively 
soft    and   pits   on    pleasure.      In    other    instances   it   is   due    to    the 


532  THE   INTESTINES 

omentum  or  an  adjacent  coil  of  bowel  having  become  adherent  to 
the  tumour. 

On  examining  the  rectum,  it  is  often  observed  that  the  external 
sphincter  is  tightly  contracted,  the  anal  canal  unduly  short,  and  the 
rectal  cavity  blown  up  with  gas,  so  that  the  finger  can  scarcely  reach 
its  walls,  a  condition  which  is  known  as  "  ballooning  of  the  rectum." 
This  is  most  frequently  observed  when  the  stricture  is  in  the  pelvic 
colon,  but  is  not  a  characteristic  sign  of  cancer. 

When  ascites  is  present,  there  are  usually  advanced  secondary 
deposits  in  the  peritoneum,  or  in  the  liver. 

As  time  goes  on,  the  patient  suffers  greatly  from  recurring  attacks 
of  colic,  during  which  visible  coils  of  intestine  may  stand  out  and  be 
felt  to  harden  as  a  wave  of  peristalsis  passes  over  them.  There  is 
increasing  distension,  and  rumbling  sounds  are  heard  in  the  abdomen. 
The  constipation  becomes  more  marked,  and,  in  spite  of  the  taking  of 
purgatives  or  enemata,  the  bowels  may  fail  to  act  for  days  or  even 
weeks,  without  acute  symptoms  of  complete  obstruction  coming  on. 

When  acute  obstruction  has  supervened. — As  a  rule,  acute  symptoms 
appear  suddenly  in  a  patient  who  has  for  some  time  shown  signs  of 
gradually  increasing  stenosis.  In  a  considerable  proportion  of  cases, 
however,  the  compensation  has  been  so  efficient  that  the  muscular 
hypertrophy  has  been  able  to  overcome  the  obstruction,  and  it  is 
only  when  a  severe  strain  is  suddenly  thrown  upon  the  musculature 
of  the  dilated  bowel — for  example  by  the  taking  of  a  strong  purgative. 
<>r  by  a  foreign  body  or  a  hardened  fsecal  mass  becoming  impacted  in 
the  stricture — that  the  compensation  fails  and  signs  of  acute  obstruction 
manifest  themselves.  The  usual  symptoms  of  acute  obstruction  are 
present,  and  there  may  be  nothing,  apart  from  the  previous  history, 
to  indicate  either  the  cause  or  the  seat  of  the  obstruction.  The  whole 
colon  above  the  stricture  usually  becomes  greatly  dilated,  the  dilatation 
supervening  rapidly,  ?nd  being  so  marked  that,  when  the  abdomen  is 
opened,  the  longitudinal  stria?  cannot  be  recognized,  and  the  peritoneal 
coat  often  splits  with  the  removal  of  the  support  of  the  abdominal  wall. 
The  distended  bowel  forces  its  way  between  the  layers  of  the  mesentery, 
which  may  become  so  much  shortened  as  to  anchor  the  gut.  Patches 
of  gangrene  may  form  on  the  dilated  bowel  and  perforation  occur, 
leading  to  peritonitis,  which  adds  to  the  distension.  Sometimes  the 
csecum  alone  is  acutely  distended,  the  other  parts  of  the  colon  above 
the  obstruction  showing  only  moderate  dilatation.  This  is  probably 
due  to  the  ileo-ea?cal  valve  remaining  competent  and  to  violent  anti- 
peristalsis  forcing  gas  and  fluid  faeces  back  to  the  ececum. 

When  the  colon  is  full  and  bulges  into  the  flanks,  it  yields  a  dull 
note  on  percussion,  and  an  apparent  sense  of  fluctuation  with  distinct 
splashing  may  be  detected  on  succussion. 


C  \KCI\o\l.\   OF   THE  COLON  533 

If  peritonitis  is  present,  there  ia  muscular  rigidity  and  fixation, 
and  if  perforation  has  occurred  the  whole  abdomen  is  uniformly  Mown 
up  and  yields  ;i  high-pitched,  drumxny  note. 

Pain  is  in. i  always  referred  to  the  position  of  the  obstruction  ;  when 
peritonitis  is  present  it  is  generally  referred  to  the  seal  of  infection. 

Vomiting  is  a  late  symptom,  and,  although  it  may  be  persistent,  it 
Beldom  becomes  stercoraceous.  Hiccup  is  often  very  intractable. 
The  patient  may  linger  on  for  some  days  in  this  condition,  bul  ulti- 
mately succumbs  to  toxaemia  or  to  exhaustion  from  the  persistenl 
vomiting  and  loss  of  fluid. 

Cancer  of  the  ccecnm  (Fig.  431). — A  palpable  tumour  is  more 
frequently  to  be  made  out  when  the  cancer  affects  the  ctecum,  and 
flatulenl  distension  and  exaggerated  peristalsis  of  the  lower  coils  of 
the  ileum  are  often  detectable.  The  pain  frequently  bears  a  distinct 
relation  to  the  taking  of  food. 

Cancer  of  the  tramverse  colon. — When  a  tumour  is  palpable,  it  is 
centrally  placed,  and  is  usually  freely  movable.  It  may  be  of  con- 
siderable size,  as  it  is  not  uncommon  for  the  omentum  to  be  rolled 
up  and  incorporated  in  the  growth,  or  for  the  lesser  omentum  and 
even  the  stomach  to  be  invaded.  The  distension  is  most  evident  in 
the  right  flank. 

Cancer  of  the  splenic  flexure. — As  the  growth  is  under  cover  of 
the  ribs,  it  cannot  be  palpated.  The  distension  affects  the  transverse 
colon,  and  the  caecum  is  sometimes  very  greatly  distended.  Peri- 
stalsis is  usually  too  feeble  to  be  recognized.  Pain  is  often  worst 
before  defsecation. 

Cancer  of  the  descending  and  pelvic  colon. — There  is  usually  a  palpable 
tumour  in  the  left  iliac  fossa,  which  may  be  fixed  by  contraction  of 
the  mesocolon,  but  in  some  cases  is  so  movable  that  it  can  be  pushed 
towards  the  middle  of  the  abdomen  or  even  to  the  right  side.  The 
tumour  can  sometimes  be  felt  on  bimanual  examination,  or  it  may  be 
seen  with  the  sigmoidoscope,  or  its  position  can  be  recognized  by 
X-ray  examination  after  injecting  an  emulsion  of  bismuth  into  the 
bowel.  The  whole  length  of  the  colon  is  distended,  the  caecum 
often  being  blown  up  to  an  enormous  extent,  and  in  rare  rases  the 
distension  involves  also  the  small  intestine,  producing  a  characteristic 
"  ladder  pattern."  It  is  in  cancer  of  the  pelvic  colon  that  balloon- 
ing of  the  rectum  is  most  frequently  present.  Constipation  is  more 
marked  than  in  cancer  higher  up,  but  it  alternates,  or  may  even  be 
associated  with  persistent  and  painful  tenesmus  and  the  passage  of 
mucus. 

Complications — In  addition  to  complete  obstruction  of  the 
bowels,  which  is  sooner  or  later  an  almost  inevitable  sequel  to  malig- 
nant disease  of  the  colon,  various  other  complications  may  arise.     The 


534 


THE    INTESTINES 


growth  may,  for  example,  form  attachments  with;  an  adjacent  portion 
of  the  alimentary  canal,  and  gradually  invade  it,  with  the  residt  that 
an  internal  fistula  is  established.     So  long  as  two  adjacent  coils  become 


Ascendina:  coluii 


Mesentery 


Tumour     involv- 
ing wall  of 
csecum 

Tumour  involv- 
ing ileo-csecal 
valve 


Lumen  of  bowel 


Cfecum \X 


Hypertrophied 

coat  of 
ileum 


Fig.  431. — Cancer  of  the  caecum. 

(Author's  case.) 

connected,  the  effects  of  the  formation  of  such  a  fistula  are  not  neces- 
sarily serious,  but  when  portions  of  the  canal  widely  separated  from 
one  another  become  fused,  the  short-circuiting  may  seriously  interfere 
with  the  nutrition  of  the  patient — for  example,  when  the  stomach  is 
invaded  by  a  growth  of  the  transverse  colon.     It  has  happened  that 


CARCINOMA   OF   THE   COLON  535 

a  fistulous  communication  between  the  intestine  above  and  thai  beyond 
the  cancez  bas  temporarily  relieved  an  obstruction.  Fistulae  may 
also  form  between  the  colon  and  the  bladder.  I  have  observed  two 
oases  in  which  fiatus  was  passed  with  the  urine;  m  one  this  con- 
tinued for  about  a  fortnight,  and  then  ceased,  and  did  oo1  recur  during 
the  fifteen  months  the  patienl  survived;  post-mortem  the  opening 
was  found  occluded  by  cicatricial  tissue  apparently  due  to  peritonitic 
adhesions.  Similar  list ula'  may  also  form  with  the  urethra,  the 
vagina,  or  t  be  skin. 

InliissKsci  /it ion  is  occasionally  induced,  and  kinking  of  the  bowel 
may  occur  and  lead  to  acute  obstruction. 

Differential  diagnosis. — In  the  absence  of  acute  obstructive 
symptoms,  the  diagnosis  of  cancer  of  the  colon  does  not  present 
.meat  difficulty.  It  is  to  be  borne  in  mind  that  in  the  colon  cancer 
occurs    at   an   earlier  age  than  in   most   other  situations.     Many  of 


the  patients  appear  to  be  in  good  general  liealtli7  and  show  no  sign 
of  what  is  spoken  of  as  a  cancerous  cachexia.  This  cachectic 
condition  only  ensues  in  the  terminal  stages  of  the  disease  when  the 
diagnosis  is  no  longer  in  doubt.  The  conditions  that  have  to  be  borne 
in  mind  when  the  symptoms  are  referred  to  the  region  of  the  caecum 
are  ileo-csecal  tuberculosis,  enterolith,  and  inflammatory  swellings 
originating  in  the  appendix  ;  in  the  region  of  the  ascending  colon  and 
hepatic  flexure,  affections  of  the  right  kidney,  the  liver  and  gall-bladder, 
the  stomach  and  pylorus,  and  the  omentum  ;  in  the  splenic  flexure 
and  descending  colon,  affections  of  the  left  kidney  and  spleen  ;  in  the 
pelvic  colon,  diseases  of  the  uterine  appendages,  fibromatosis  of  the 
colon,  and  fsecal  accumulation. 

When  symptoms  of  acute  obstruction  are  present,  apart  from 
the  history,  there  is  nothing  characteristic  of  cancerous  stricture,  and 
all  other  causes  of  obstruction  have  to  be  considered.  It  is  often 
impossible  to  arrive  at  a  diagnosis  without  opening  the  abdomen. 

Treatment. — As  the  disease  remains  for  a  considerable  time 
confined  to  the  bowel  and  is  slow  to  implicate  the  mesenteric  glands, 
a  radical  operation,  if  undertaken  before  there  is  much  distension  of 
the  bowel  above  the  stricture  and  before  obstructive  symptoms  have 
appeared,  affords  a  considerable  prospect  of  permanent  cure.  The 
radical  operation  consists  in  removing  the  affected  segment,  as  well 
as  several  inches  of  the  bowel  above  and  below  it,  together  with  the 
lymphatic  vessels  draining  the  bowel,  the  glands  into  which  these 
lymphatics  open,  and  the  connective  tissue  in  which  they  lie.  The 
continuity  of  the  tube  is  re-established  either  by  end-to-end  suture 
or  by  lateral  anastomosis.  With  the  patient  in  the  Trendelenburg 
position,  an  incision  is  made  which  will  give  free  access  to  the  tumour. 
To   enable  the   ends  to  be   brought   together  without   tension,  it   is 


536  TIN-.    [NTESTINES 

advisable  to  "mobilize"  the  segment  to  be  dealt  with,  by  dividing 
the  reflection  of  the  peritoneum  on  to  the  parietes  and  stripping  it 
towards  the  middle  line. 

In  the  great  majority  of  cases,  the  patient  is  alreadv  suffering 
from  obstructive  symptoms  before  the  question  of  operation  is  raised, 
and  the  bowel  is  more  or  less  distended  above  the  stricture.  "Wlien 
acute  obstructive  symptoms  are  present,  it  is  seldom  possible  to  locate 
the  tumour,  and  the  abdomen  is  best  opened  to  the  right  of  the  middle 
line  below  the  level  of  the  umbilicus.  Under  these  conditions,  the 
resection  should  always  be  done  by  the  "  two-stage  "  method,  the 
obstruction  being  relieved  by  opening  and  draining  the  distended 
bowel,  and  the  growth  removed  at  a  later  date.  If  it  is  possible  at 
the  first  operation  to  bring  the  tumour  out  to  the  surface,  this  should 
be  done,  as  it  greatly  facilitates  the  second  stage  of  removal. 

The  second  stage  should  be  carried  through  as  soon  as  the  bowel 
has  been  completely  emptied  and  the  patient  has  sufficiently  recovered 
from  the  effects  of  the  obstruction  and  the  primary  operation.  This 
is  usually  in  from  three  to  seven  days. 

If,  after  relieving  the  obstruction,  it  is  found  to  be  impossible  to 
resect  the  growth,  the  patient  may  be  saved  the  discomfort  of  a  per- 
manent artificial  anus  and  his  life  may  be  prolonged  by  entero-anasto- 
mosis,  the  bowel  above  and  below  the  stricture  being  united. 

Sarcoma  of  the  colon. — Sarcoma  of  the  colon  is  a  rare 
disease,  and  is  usually  met  with  in  the  csecum.  It  occurs  in  young 
subjects  as  a  diffuse  infiltration  of  the  coats  of  the  bowel,  converting 
it  into  a  rigid  tube.  The  mucous  membrane  as  a  rule  is  tightly  stretched 
over  the  tumour,  which  tends  to  grow  towards  the  lumen  of  the  bowel. 
Obstruction  is  not  a  common  manifestation  of  the  disease.  As  a 
rule,  the  disease  is  characterized  by  a  general  weakness,  loss  of  flesh, 
and  the  development  of  a  rapidly  growing  abdominal  swelling. 

If  the  disease  is  diagnosed  early,  the  affected  segment  of  bowel 
should  be  removed  on  the  same  lines  as  for  carcinoma,  and  experience  has 
shown  that  the  results  of  early  operation  are  on  the  whole  satisfactory. 

BIBLIOGRAPHY 

Barnard,  H.  L.,  Contributions  to  Abdominal  Surgery.     1910. 

Berry  and  Giuseppi,  Proc.  Boy.  Soc.  Med.,  Nov.,  1908. 

Caird,  F.  M.,  Scot.  Med.  and  Surg.  Journ.,  1904,  xiv. 

Goodall,  Harry  W.,  Boston  Med.  and  Surg.   Journ.,  April,  1910. 

Hartmann,  Rev.  de  Chir.,  Feb.,  1907. 

Keith,  Arthur,  Brit.  Med.  Journ.,  Feb.  5,  1910. 

Miles,  Alexander,  Edin.  Med.  Journ.,  1910,  i. 

Paterson,  H.  J.,  Proc.  Roy.  Soc.  Mid.,  June,  1909. 

Pavlov,  The  Work  of  the  Digestive  Glands,  2nd  Edit.     1910. 

Proc.  Roy.  Soc.  Med.,  1909,  pp.  59-99,  Discussion  in  Med.  Sec.  on  Ulcerative  Colitis. 

Thomson,  Alexis,  Edin.  Med.  Journ.,  April,  1908. 

Wilkie,  D.  P.  D.,  Edin.  Med.   Journ.,  1909,  ii.,  and  Oct.,  1910. 


THE    APPENDIX 

By   PERCY  SARGENT,   M.A.,  M.B.,  B.C.Cantab., 
F.R.C.S.ENG. 

Anatomy  and  physiology. — The  appendix  is  a  blind  tubular 
diverticulum  springing  from  the  inner  and  posterior  aspect  of  the 
caecum  at  a  point  about  2  in.  from  the  ileo-caecal  valve.  In  the 
foetus  and  in  the  infant  it  forms  the  apex  of  the  caecum,  and  when 
this  condition  persists  in  adult  life  the  caecum  is  said  to  be  of  the 
foetal  type.  The  sacculations  of  the  adult  caecum  which  displace 
the  appendix  from  its  apical  position  are  of  secondary  formation: 
The  appendix  attains  its  maximum  development  in  young  adult 
life,  and  after  middle  age  it  is  said  slowly  to  atrophy.  In  old  age 
it  may  be  found  represented  by  a  mere  fibrous  cord. 

Length. — The  average  length  of  the  appendix  is  between  3  and 
4  in.,  varying  from  \  in.  or  even  less  up  to  as  much  as  9  in. 
(R.  Berry).  Whilst  its  average  diameter  is  about  \  in.,  its  lumen, 
unless  occupied  by  pathological  material,  is  very  narrow.  The  caecal 
orifice  is  sometimes  marked  by  a  feebly  developed  valve-like  fold  of 
mucous  membrane  (Gerlach's  valve). 

Position. — The  appendix  occupies  no  constant  anatomical  posi- 
tion, the  variations  in  this  respect  being  due  to  its  free  mobility.  The 
situations  in  which  it  is  most  frequently  found  are  (1)  to  the  inner 
side  of  the  caecum,  pointing  upwards  and  leftwards  towards  the  spleen 
(38  per  cent.,  H.  P.  Hawkins) ;  (2)  pointing  upwards  behind  the 
caecum,  where  it  often  occupies  and  is  concealed  in  the  retrocolic 
fossa  (26  per  cent.) ;  and  (3)  hanging  over  the  pelvic  brim  (17  per 
cent.).  It  will  be  readily  understood  that  the  position  in  which  the 
appendix  happens  to  lie  when  it  becomes  acutely  inflamed  or  per- 
forated will  determine  the  situation  of  a  resulting  abscess  or  the  direc- 
tion of  spread  of  a  diffuse  peritonitis. 

Surface  marking. — McBurney's  point  is  situated  upon  a  line 
drawn  from  the  anterior  superior  iliac  spine  to  the  umbilicus  (spino- 
umbilical  line)  and  about  2  in.  internally  to  the  iliac  spine.  This  does 
not  represent  the  situation  of  the  appendix,  but  is  said  to  be,  as  a  rule, 

537 


538  THE    APPENDIX 

the  point  of  greatest  tenderness  in  appendicitis.  Munro's  point  is  the 
spot  at  which  the  spino-umbilical  line  crosses  the  outer  border  of  the 
rectus  muscle  or  linea  semilunaris.  According  to  A.  Keith,  the  ileo- 
caecal  valve  is  the  part  of  the  intestine  which  most  often  lies  directly 
beneath  Munro's  point,  so  that  the  appendicular  orifice  will  usually  be 
found  about  an  inch  below  and  to  the  outer  side  of  Munro's  point. 

Structure. — The  coats  of  the  appendix  consist  of  (1)  a  mucous 
membrane,  containing  innumerable  Lieberkuhn's  glands,  and  resting 
upon  a  very  faintly  marked  muscularis  mucosae  ;  (2)  a  submucous 
layer,  extremely  rich  in  lymphoid  tissue  ;  (3)  a  muscular  layer,  com- 
prising inner  circular  and  outer  longitudinal  strata  corresponding  with 
the  muscular  layers  of  the  caecum,  but  differing  in  the  fact  that  the 
outer  layer  is  disposed  uniformly  over  the  surface  instead  of  being 
grouped  into  distinct  bands ;  and  (4)  a  peritoneal  coat,  separated  from 
the  muscle  by  a  small  amount  of  subserous  connective  tissue.  The 
peritoneal  covering  is  complete,  except  just  along  the  fine  of  attach- 
ment of  the  mesentery  where  the  vessels  enter  and  leave  the  organ. 
The  meso-appendix  connects  the  little  process  to  the  mesentery  of 
the  termination  of  the  ileum,  springing  from  its  inferior  aspect,  and 
is  often  so  short  as  to  render  the  appendix  tortuous  ;  it  is  sometimes 
heavily  loaded  with  fat. 

Blood-vessels. — The  appendix  is  supplied  by  a  branch  of  the 
ileo-caecal  artery,  the  termination  of  the  superior  mesenteric,  which 
passes  down  behind  the  termination  of  the  ileum,  and  enters  the 
meso-appendix.  to  be  distributed  to  the  organ  by  a  series  of  circularly- 
disposed  branches.  The  veins  are  arranged  in  a  similar  manner,  and 
are  radicles  of  the  portal  system. 

Lymphatics. — The  lymphatics  are  collected  into  four  or  five  trunks 
which  pass  with  the  appendicular  artery  between  the  layers  of  the 
meso-appendix  and  travel  behind  the  termination  of  the  ileum  to  end 
in  the  ileo-caecal  glands — a  group  of  some  five  or  six  glands  situated 
between  the  layers  of  the  mesentery  of  the  small  intestine  in  the  upper 
ileo-caecal  angle  (Poirier  and  Cuneo). 

Peritoneal  relations. — The  clinical  significance  of  the  various 
positions  in  which  the  appendix  may  be  found  will  be  readily  under- 
stood when  considered  in  connexion  with  the  peritoneal  watersheds 
(p.  559).  In  addition  to  the  meso-appendix,  there  is  a  second  peri- 
toneal fold,  occasionally  well  marked,  which  passes  from  the  anterior 
aspect  of  the  termination  of  the  ileum  to  the  front  of  the  appendicular 
mesentery.  This  is  the  ileo-caecal  fold  (the  so-called  "  bloodless  fold  "), 
which  bounds  the  ileo-caecal  fossa.  The  appendix  is  frequently  lodged 
in  the  retrocaecal  fossa,  a  peritoneal  pouch  which  may  be  demonstrated 
by  drawing  the  caput  coli  upwards. 

Physiology. — The  appendix  is  a  vestigial  structure  whose  func- 


MISPLACEMENT   OF   THE    APPENDIX 

tions,  if  any,  are  of  little  moment.  Experience  baa  amply  proved  that 
its  removal  is  followed  by  no  demonstrable  alteration  in  the  economy. 
It  has  been  variously  credited  with  the  provision  of  some  secretion 
which  prevents  faecal  hardening  in  the  caecum  ;  with  being  concerned 
in  the  digestion  of  vegetable  material;  with  providing  a  fluid  which 
stimulates  peristaltic  activity  in  the  caecum;  and,  on  account  oJ 
the  Large  quantity  of  lymphoid  tissue  which  it  contain-,  with  having 
to  do  with  the  disposal  of  bacteria.  W,  Macewen  believes  thai  the 
appendix  possesses  definite  and  important  functions.  He  regard-  it  as 
a  sort  of  culture-tube  from  which,  in  response  to  the  stimulus  provided 
by  the  passage  of  the  intestinal  contents  over  its  orifice,  bacteria  in  a 
proper  state  of  activity  are  from  time  to  time  discharged  into  the 
caecum,  where  they  assist  in  the  disintegration  of  undigested  food- 
stuff-. 

Misplacement  of  the  appendix. — The  various  position- 
occupied  by  an  appendix  hang  in  the  right  iliac  region  can  scarcely  be 
termed  abnormalities,  as  there  is  no  "  normal "  position  with  which 
to  compare  them.  The  organ  is,  however,  sometimes  found  in  situa- 
tions so  remote  from  its  usual  position  as  to  constitute  misplacements, 
and  such  variations  are  due  either  to  (a)  arrest  in  the  development 
and  descent  of  the  caecum,  or  (b)  the  presence  of  abnormally  long  and 
voluminous  mesenteries. 

(a)  Misplacement  due  to  arrest  of  development.— During 
the  development  of  the  colon  the  caecum  passes  from  the  left  hypochon- 
drium  across  the  upper  part  of  the  abdomen  to  the  under  surface 
of  the  liver,  and  then  downwards  until  it  reaches  its  final  adult 
position  in  the  right  iliac  fossa.  Arrest  of  development  may  cause 
the  appendix  to  occupy  any  position  upon  this  line  of  descent ; 
consequently  it  has  been  found  near  the  spleen,  in  the  epigastrium, 
beneath  the  liver,  and  at  various  points  in  the  right  loin  between 
the  liver  and  the  right  iliac  fossa. 

(6)  Mesenteric  abnormalities. — A  long  mesocolon,  such  as  that 
which  predisposes  to  the  production  of  a  volvulus  of  the  caecum,  is  not 
infrequently  responsible  for  abnormal  positions  of  the  appendix,  especi- 
ally when  combined  with  elongation  of  the  meso-appendix.  Thus  the 
appendix  may  be  entirely  in  the  pelvis,  where  it  may  be  adherent  to 
the  uterus,  broad  ligament,  or  bladder  ;  it  may  lie  entirely  upon  the 
left  side  of  the  body,  and  be  found  in  the  left  loin  or  left  iliac  fossa  ; 
or  it  may  occupy  any  position  amongst  the  intestinal  coils.  A  long 
meso-appendix.  apart  from  any  abnormality  of  the  mesocolon,  may 
allow  of  abnormal  positions  being  assumed  by  the  appendix  through 
its  tip  becoming  adherent  to  other  viscera  and  being  pulled  upon  by 
them.  Thus  the  tip  of  a  long  appendix  with  a  long  mesentery,  having 
become  adherent  to  the  pelvic  colon,  may  be  drawn  upon  so  that  it 


54°  THE   APPENDIX 

stretches  across  the  abdomen  and  lies  partly  upon  the  left  iliac  fossa. 
Similarly  it  may  become  pulled  upon,  elongated,  and  displaced  by  any 
coil  of  small  intestine  to  which  it  may  have  become  adherent. 

Just  as  mesenteric  abnormalities  permit  of  the  appendix  being 
found  in  many  abnormal  positions  within  the  abdomen,  so  they  .also 
allow  of  its  appearance  in  hernial  sacs,  and  the  organ  has  often  been 
found  in  right-sided  femoral  and  inguinal  hernias  ;  less  often  in  um- 
bilical and  in  left-sided  femoral  and  inguinal  hernias.  It  may  be  found 
either  alone  or  in  company  with  other  viscera. 

In  the  rare  instances  of  transposition  of  viscera,  the  caecum  and 
appendix  are  found  in  the  left  iliac  fossa,  but  with  their  relations  to 
one  another  and  to  other  viscera  otherwise  unaltered. 

APPENDICITIS 

Etiology — Appendicitis  is  a  disease  essentially  dependent  upon 
bacterial  activity,  which  may  be  brought  about  or  contributed  to  by 
a  number  of  subsidiary  causes. 

Bacteriology. — The  great  majority  of  cases  of  appendicitis  are 
caused  by  the  Bacillus  coli  (see  Peritonitis,  p.  565).  Other  organisms 
have  from  time  to  time  been  found  in  or  around  an  inflamed  appendix, 
such  as  the  Pneumococcus  (J.  Eyre),  the  pathogenetic  staphylococci 
(Tavel  and  Lanz),  the  Streptococcus  pyogenes  (dishing),  certain 
anaerobes  (Veillon  and  Zuber),  and  the  Bacillus  pyocyaneus  (Dudgeon 
and  Sargent)  ;  and  whilst  it  must  be  admitted  that  any  of  these 
organisms  may  be  occasional  causes  of  the  disease,  yet  there  is  no 
doubt  that  the  colon  bacillus  is  by  far  the  most  frequent  causal 
agent  (Dudgeon  and  Sargent). 

Accessory  causes. — Age  is  a  most  important  factor  in  the  inci- 
dence of  appendicitis,  and  its  greater  frequency  in  young  adult  life  is 
probably  related  to  the  maximum  development  of  the  lymphoid  tissue 
which  is  noted  at  that  period.  The  disease  is  rare  in  infancy  and 
becomes  increasingly  frequent  between  the  ages  of  10  and  20,  when 
the  maximum  is  reached  ;  from  20  to  30  the  age-incidence  falls  but 
little  ;  whilst  from  30  to  40  the  diminution  is  considerable  ;  after  40 
it  becomes  less  and  less  frequent,  until  in  old  age  it  is  as  rare  as  in 
infancy. 

Sex  can  scarcely  be  cited  as  a  cause,  for  there  is  no  obvious  reason, 
anatomical  or  pathological,  why  the  disease  should  occur  more  often 
in  one  sex  than  in  the  other.  Yet  it  is  a  fact  that  all  large  series  of 
cases  show  a  distinct  preponderance  of  males,  the  proportion  of  males 
to  females  being  variously  estimated  as  hang  between  2  to  1  and  3  to  1. 

Heredity. — There  is  some  reason  for  thinking  that  the  tendency  to 
appendicitis  runs  in  families.  If  this  is  so  it  may  perhaps  be  ascribed 
to  similaritv  of    anatomical    conformation   favouring  the  disease,   to 


A.  Appendix   distended    by    a    large    concretion.      The   serous    and    muccular   coats    ha\e 

been  cut   away  to  show    the    mucosa    stretched  over   the   concretion,   and  ulcerated 
at  a.     {Specimen   1107E.   St.    Thomas's  Hospital  Museum.) 

B.  Acutely    inflamed     appendix    from    a     boy    aged    7,    removed    fifteen     hours    after    the 

onset.     At  b  the  wall  consists  of  the  serous  coat  only  :    the  mucosa  is  gangrenous. 
The   patient  recovered. 

C.  Perforated    appendix,   with    concretion,   from    a  woman  aged    35.   removed    forty -eight 

hours  after  the  onset.     The  patient   recovered. 

D.  Gangrenous    appendix,     with     concretion,    from     a    fatal     case.        (Specimen    11078  A, 

St.    Thomas's  Hospital  Musen»i.) 


Plate  97. 


APPENDICITIS:    ETIOLOG1  541 

similar  lack  of  resistance  to  l>.  coli  infection,  01  fco  similar  habits  of 
diet  in  members  of  the  same  family. 

Dietetio  errors  and  ohronic  constipation  undoubtedly  influence  the 

incidence  of  the  disease.    Conversely,  it  .seems  probable  thai   ohronic 
disease  of  1  he  appendix  is  a  factor  in  the  production  of  various  intestinal 

disorders,  so  that  the  diseased  appendix  becomes  a  link   in  a  vicious 
circle. 

Injur//  has  been  credited  with  being  a  factor  in  the  causation  of 
appendicitis,  since  a  certain  number  of  patients  give  a  history  either  of 
some  abrupt  and  unaccustomed  strain  or  of  a  direct  abdominal  injury 
(6'6  per  cent.,  von  Neumann).  Byrom  Eobinson  has  suggested  that 
the  injury  caused  by  the  constant  action  of  the  underlying  psoas  muscle 
may  be  responsible  for  some  cases. 

Foreign  bodies  and  concretions. — Pins,  bristles,  hairs,  grains  of  corn, 
fruit-seeds,  and  other  foreign  bodies  have  been  found  in  inflamed 
appendices,  but  their  occurrence  is  so  uncommon  as  to  constitute  a 
curiosity.  Fsccal  concretions,  on  the  other  hand,  are  found  in  about  25 
per  cent,  of  cases. 

Parasites. — Threadworms  are  not  infrequently  found  in  appendices 
removed  at  operation.  In  200  post-mortem  examinations  of  children, 
G.  F.  Still  found  the  oxyuris  in  the  appendix  25  times. 

Inflammation  of  adjacent  structures,  such  as  an  ovarian  cyst,  rnay 
involve  the  appendix  secondarily;  on  the  other  hand,  these  structures 
may  be  secondarily  infected  from  a  diseased  appendix.  The  coexist- 
ence of  pelvic  disease  with  appendicitis  is  well  known. 

Many  other  factors  have,  on  slender  grounds  for  the  most  part,  been 
cited  as  causes  of  appendicitis',  such  as  exposure  to  cold,  rheumatism, 
and  influenza.     These  need  but  passing  notice. 

Appendices  in  abnormal  situations  are  very  prone  to  become  the 
seat  of  disease,  as  for  example  in  hernias.  In  a  similar  manner  the 
appendix  utilized  in  the  operation  of  appendicostomy  is  very  liable 
to  become  inflamed  and  gangrenous.  When  this  happens  it  is  possible 
to  watch  the  course  of  a  case  of  appendicitis  in  the  abdominal  wall, 
and  uncomplicated  by  peritoneal  involvement. 

Morbid  anatomy  (Plate  97). — Inflammatory  changes  in  the 
appendix  may  be  of  any  degree,  from  those  of  a  superficial  catarrh  up 
to  total  gangrene.  In  the  mildest  cases  the  mucous  membrane  is 
swollen  and  reddened,  with  but  slight  infiltration  of  the  more  ex- 
ternal layers,  and  with  little  or  no  periappendicular  effusion.  An 
increase  of  secretion  occurs  which,  if  the  appendix  be  patent,  escapes 
into  the  caecum,  and  the  inflammation  subsides,  leaving  little  trace 
behind.  Kepeated  attacks  of  such  a  catarrhal  inflammation  leave  the 
appendix  thickened,  firm  to  the  touch,  and  often  adherent  to  sur- 
rounding structures ;  its  lumen  is  narrowed,  and  the  lining  membrane 


542 


THE   APPENDIX 


is  swollen  and  mottled  in  appearance.     In  some  instances  the  lumen 

is  wholly  or  partly  obliterated  (Fig.  432). 

If  the  secretion  in  a  catarrhal  appendicitis  is  unable  to  escape  freely 

into  the  caecum,  several  results  may  occur,  depending  partly  upon  the 

completeness  of  the  obstruction,  but  chiefly  upon 

)         —  the  degree  of  bacterial  activity  within  the  organ. 

|  With  complete  obstruction  and  mild  bacterial 

"T        «  activity  a   cyst  mav  result,   containing  clear  or 

u  Turbid    fluid,    and  occasionally  attaining  a  large 

£  size  (Fig.  433).     The  fluid  may  prove  to  be  sterile. 

£  With    onlv    partial    obstruction   a   concretion 

mav  be  formed  consisting  of   a  mass  of  mspis- 

•B  3  sated  mucus   and   faecal   matter.     These   concre- 

,JT  3   ^     tions  frequently  present,  on  section,  a  laminated 

S3  ts    5      appearance,  as  though  added  to  from  time  to  time 

°>  Sj    ^      by  the  deposition  of  fresh  layers  (Fig.  434).     In 

_§  ~    <      appearance  they  often  resemble  a  cherry-stone  or 

3  "2    s"     a   date-stone ;  and  it  is  this  resemblance  which 

0    „      has  given  rise  to  the  popular  notions  as   to  the 

."ti  0    1     danger  of  swallowing  such  objects.  -Occasional!}' 

c    ^      a  concretion  attains   a   large  size   and   resembles 

SP-o    <      a  gall-stone.     Once  a  concretion  has  formed  and 

•2  "K     '■      is  unable  to  escape  into  the  caecum,  it  becomes  a 

c  £    I     source  not  only  of  discomfort  but  also  of  danger 

_•„  8    ?      to    its    possessor,    inducing    repeated   attacks    of 

*  g   -|      inflammation,    and    threatening    ulceration    and 

^  m    ->     perforation.     If   a  concretion   is   able   to   escape 

S  rt  into  the  caecum,   or  to  be  shifted  to  a  different 

S^  spot    in    the    appendix,    the    ulcerated    surface 

against   which  it  lav  becomes  cicatrized,  and  a 
c  - 

<  stricture  results. 

When  the  bacterial  activity  is  great  the  in- 

■  J     5  flammatory  changes  are   of   a  more  pronounced 

J      ^  nature,  and  a  more  advanced  series   of   changes 

/j  )  £  takes    place.      The    inflammation    involves    the 

whole    thickness  of    the   appendicular  vail,   and 

the  bacteria  are  able  to  pass  into  the  subserous  tissue  and  finally  to 

infect  the  peritoneum.     The  most   virulent  forms  of  peritonitis  can 

occur  from  the  migration  of  bacteria  through  the  wall  of  an  inflamed 

but    unperforated    appendix.      Bacterial    invasion    of    the    peritoneal 

cavity  may  take  place  in  other  ways  also — (1)    thrombosis  of   the 

appendicular  vessels  followed  by  gangrene  of  the  organ  en   masse ; 

(3)  localized   gangrene   from  vascular  disturbance,   or  from   pressure 

over  a  concretion,  leading  to  rupture  or  perforation  of  the  appendix 


/ 


APPENDICITIS:    MOKlill)    ANATOMY 


.543 


Fig.  433.— An  appendix  which  has  been  converted  into  a  cyst. 

[Specimen   1098.  St.    Thomas's  Hospital  Museum.) 

at  the  gangrenous  spot  (Fig.  435) ;  (3)  ulcera- 
tion over  a  concretion,  or  deep  ulceration  inde- 
pendent of  the  presence  of  a  concretion,  followed 
by  rupture  of  the  appendix  at  that  spot.  .  A 
foreign  body  sometimes,  but  rarely,  acts  in  the 
same  manner  as  a  concretion,  and  a  sharp- 
pointed  foreign  body  such  as  a  pin  may  per- 
forate the  appendix  mechanically  (Fig.  436). 

When  those  processes  which  entail  the  passage 
of    bacteria  through  the  appendicular  wall  take 
place    slowly  and  gradually,  the  natural    defen- 
sive powers  of    the    peritoneum  are    called  into 
play  {see  under  Peritonitis,  p.  562).     Around  an    FiS-  ^j? Va ^endT 
inflamed  appendix  there  is  always  a  little  turbid     cuiar      concretion 
peritoneal  exudate,  rich   in  phagocytes,  which  is     showing  the  lami- 
capable  of  dealing  with  the  bacteria  coming  from  nation, 

the    appendix,   provided    that    an   overwhelming  /«,«  1002. 

amount    of    virulent    material-  I  suddenly  ,,„.) 


544 


THE   APPENDIX 


discharged  into  the  peritoneal  cavity.  This  constitutes  the  first  and 
chief  line  of  resistance.  The  second  protective  process  lies  in  the 
formation  of  adhesions,  so  that  when  the  perforation  does  occur  it  is 
not  into  the  general  cavity  but  into  a  localized  portion  of  it  (Fig. 
437).  In  this  manner  the  effect  of  the  bacterial  invasion  of  the 
peritoneal  cavity,  whether  with  or  without  gross  perforation  of   the 

appendix,  is  the  pro- 
duction of  a  localized 
abscess. 

When  these  protec- 
tive agencies,  either  from 
want  of  time  or  from 
lack  of  resistance  on 
the  part  of  the  indi- 
vidual, fail  to  limit  the 
fection,  a  diffuse, 
spreading  peritonitis  re- 
sults. 

A.     ACUTE 

FORMS  OF 

APPENDICITIS 

Clinical  fea- 
tures.—  The  va- 
rious morbid  con- 
ditions of  the 
appendix  indicated 
above  bear  but 
little  relation  to 
the  clinical  course 
of  the  disease.  A 
rapidly  fatal  diffuse  peritonitis  may  spread  from  an  appendix  which 
to  the  naked  eye  appears  only  reddened  and  swollen,  but  imper- 
forated, or  a  gangrenous  perforated  appendix  may  be  found  in  a 
completely  localized  abscess  cavity.  Nor  is  there  any  means  of  re- 
cognizing clinically  the  presence  of  constrictions,  adhesions,  or  con- 
cretions, with  the  possible  exception  of  the  latter,  which  have  some- 
times been  demonstrated  by  means  of  the  X-rays.  It  is  not  possible, 
therefore,  to  make  clinical  subdivisions  to  correspond  with  the  various 
pathological  conditions  enumerated  above. 

Appendicitis  presents  itself  in  many  different  degrees  of  severity, 
all  of  which  pass  by  gentle  gradations  into  one  another.  Neverthe- 
less, certain  common  types  of  the  acute  disease  may  be  recognized,  so 


Fig.  435. — A  gangrenous  perforated  appendix, 
from  a  fatal  case. 

(Specimen  1103,  St.    Thomas's  Hospital  Museum.) 


ACUTE     APPENDICITIS 


th.it   the  clinical  course  may  conveniently  be  described  under  three 
(leadings  : — 

1.  Acute  01  Bubacute  attacks,  without  perforation  or  gangrene, 
wul  associated  with  a  mild  and  local  peritonitis  in  the  immediate 
neighbourhood  <  >  f  the  appendix. 

2.  Acute  attacks  associated  with  ulceration,  perforation,  or  gangrene, 
resulting  in  the  formation  of  a  localized  abscess  around  the  appendix. 


Sp-' 


P 


Fig.  -436. — -Perforation  of  the  appendix  by  a  pin. 

[Specimen  109811.  St.   Thomas's  Hospital  Museum.) 

—  3.  Acute  attacks  associated  with  the  passage  of  virulent  bacteria 
com  the  inflamed  appendix  into  the  peritoneal  cavity,  either  with 
r  without  gross  perforation  or  gangrene,  and  resulting  in  a  diffuse, 
preading  peritonitis. 

For  the  sake  of  brevity  these  may  respectively  be  termed — (1) 
cute  appendicitis,  (2)  appendicitis  with  local  abscess,  and  (3)  appen- 
icitis  with  diffuse  peritonitis. 

1.  ACUTE    APPENDICITIS 
Symptoms. — The  attack  may  be  sudden  and  unexpected,  or  it 
lav  be  preceded  by  certain  symptoms  which  are  termed  prodromal. 

'  -V 


54^ 


THE   APPENDIX 


Amongst  these  may  be  mentioned  an  indefinite  feeling  of  malaise, 
indigestion,  constipation,  diarrhoea,  and  vague  abdominal  discomfort. 
Whether  preceded  by  prodromal  symptoms  or  not,  the  attack  begins 
with  an  acute  pain  in  the  abdomen,  often  quite  sudden  in  its  onset, 
which  at  first  cannot  be  localized  and  may  be  referred  to  the  epi- 
gastrium or  to  the  umbilicus.  The  pain  is  rapidly  followed  by  nausea 
and  vomiting,  and  this  is  very  soon  succeeded  by  a  rise  of  temperature, 
occasionally  with  an  initial  rigor,  accompanied  by  the  usual  consti- 
tutional symptoms 
of  toxic  fever.  The 
bowels  may  act 
once  or  twice  after 
the  onset,  but  then 
constipation  usually 
becomes  a  promin- 
ent feature.  Excep- 
tionally the  bowels 
act  naturally 
throughout,  and 
some  of  the  severer 
cases  are  attended 
with  diarrhoea. 

Examination 
shortly  after  the 
onset  shows  the  ab- 
domen to  be  rigid, 
motionless,  and  uni- 
formly tender ;  these 
signs  soon  become 
localized  to  the 
right  iliac  region, 
and  the  spot  of  most 
acute  tenderness  is  commonly  found  to  correspond  with  McBurney's 
point.  The  abdomen  is  usually  a  little  distended,  and  may  be  markedly 
so  ;  the  distension  may  be  limited  to  the  lower  half  of  the  abdomen, 
and  even  to  the  right  iliac  region.  Very  soon  an  indefinite  swelling 
can  be  felt  in  the  right  iliac  fossa,  which  in  two  or  three  days  becomes 
palpable  as  a  more  or  less  definite  mass.  Muscular  rigidity  often 
causes  a  localized  swelling  which  may  readily  be  mistaken  for  a 
subjacent  inflammatory  tumour.  In  some  cases  symptoms  referable  to 
the  bladder  are  present,  namely,  pain,  frequency  of  micturition,  or 
retention  of  urine.  Rectal  pain  and  tenesmus  may  also  be  experienced. 
In  these  instances  examination  per  rectum  usually  reveals  the  pre- 
sence of  a  tender  inflammatory  mass  in  the  right  side  of  the  pelvis. 


Fig.  437. — From  a  case  of  acute  appendicitis  of 
three  days'  duration  in  a  youth  aged  17. 
The  distal  end  had  perforated  into  an 
omental  pocket. 


APPENDICITIS  547 

Meanwhile  t ho  temperature  La  raised,  ranging  Erom   Km i    to  103    oj 
104°;    the    pulse-rate  is  correspondingly  accelerated,   the  tongue   ie 

furred,  and  the  appetite  lost.     These  symptoms  Last  from  about  three 

to  ten  days  according  to  the  Severity  of  the  at  lade. 

2.  APPENDICITIS  WITH  LOCAL  ABSCI 

The  symptoms  at  first  are  the  same  as  those  described  above, 
except  that  they  are  usually  more  severe,  though  this  is  not  necessarilv 
the  case.  The  probability  of  abscess  formation  increases  in  propor- 
tion as  the  symptoms  of  fever  and  the  local  signs  persist  beyond  the 
customary  time  for  an  ordinary  attack  to  last.  The  presence  of  a  tumour 
in  the  right  iliac  fossa  which  increases  in  size  and  definition,  especial lv 
when  diarrhoea  replaces  the  initial  constipation,  or  the  existence  of  a 
tender  pelvic  mass  together  with  vesical  symptoms  at  a  time  when  an 
ordinary  attack  would  naturally  be  clearing  up,  indicates  the  formation 
of  an  abscess.  The  patient  prefers  to  lie  with  the  right  thigh  drawn 
up,  full  extension  being  painful. 

Leucocytosis  is  regarded  by  some  as  of  value  in  the  diagnosis  of 
abscess  ;  but,  like  the  elevation  of  temperature,  it  is  to  be  taken  as 
an  indication  of  absorption  and  reaction  rather  than  of  the  actual 
presence  of  pus,  for  a  large  completely  walled-off  abscess  may  exist 
without  either  leucocytosis  or  fever. 

In  a  neglected  case  the  skin  of  the  abdominal  wall  may  become 
cedematous  and  reddened,  and  it  may  even  be  possible  to  detect  fluc- 
tuation ;  but  this  is  a  sign  which  is  rarely  present,  and  should  never 
be  expected.  If  untreated  the  pus  may  make  its  way  to  the  surface, 
but  it  is  much  more  likely  to  rupture  into  the  general  peritoneal  cavity, 
the  bowel,  vagina,  or  bladder  ;  or  it  may  track  upwards  to  the  sub- 
phrenic region  and  rupture  into  the  pleura  or  respiratory  passages. 

3.  APPENDICITIS  WITH  DIFFUSE  PERITONITIS 

The  rupture  or  perforation  of  a  diseased  appendix,  giving  rise  to 
a  diffuse  peritonitis,  may  be  abrupt  and  unexpected. 

A  patient,  apparently  in  perfect  health,  may  be  suddenly  seized 
with  violent  abdominal  pain  and  vomiting,  and  rapidly  evince  the 
symptoms  of  profound  collapse.  Often  there  are  premonitory  symp- 
toms of  a  more  or  less  definite  character  pointing  to  appendicitis,  but 
in  most  cases  the  onset  of  the  peritonitis  is  sudden  or  at  least  rapid. 
In  some  instances  the  actual  moment  of  perforation  is  indicated 
by  sudden  relief  of  the  pain  due  to  distension  of  an  acutely  inflamed 
appendix  ;  in  others  the  peritonitis  spreads  swiftly,  but  more  insidi- 
ously, from  an  imperfectly  shut-off  collection  of  pus  around  the  appen- 
dix ;  in  others,  again,  the  rupture  of  a  localized  abscess  provides  the 
starting-point  of  a  diffuse  peritonitis. 


54«  THE    APPENDIX 

The  symptoms  of  this  form  of  acute  appendicitis  are  therefore  those 
of  diffuse  peritonitis  (see  p.  567),  either  of  sudden  and  unexpected 
onset,  added  to  those  of  a  pre-existing  acute  appendicitis,  with  or 
without  periappendicular  abscess. 

Diagnosis  of  acute  forms  of  appendicitis. — The  diag- 
nosis of  an  ordinary  attack  of  acute  appendicitis  presents  little  diffi- 
culty, nor,  as  a  rule,  do  the  history,  s}Tmptoms,  and  physical  signs  of 
the  cases  complicated  by  gross  peritoneal  infection  leave  much  room 
for  doubt  as  to  the  nature  of  the  illness.  In  the  less  acute  cases  the 
difficulty  is  greater,  particularly  as  there  is  a  growing  tendency  to 
ascribe,  often  on  slender  evidence,  vague  abdominal  symptoms  of  all 
kinds  to  pathological  conditions  of  the  appendix. 

The  diagnosis  embraces  two  distinct  considerations,  namely,  the 
discrimination  of  appendicitis  from  other  conditions,  and  the  recogni- 
tion of  the  stage  and  severity  of  the  appendicitis. 

1.  Acute  appendicitis  may  be  simulated  by — 

(a)  Pelvic  causes. — Salpingitis,  pyosalpinx,  ruptured  tubal  preg- 
nancy, and  inflammation  or  the  twisting  of  the  pedicle  of  a  small 
ovarian  cyst,  are  to  be  eliminated  by  the  history,  together  with  a 
careful  bimanual  examination  of  the  pelvis.  At  the  same  time,  the 
possibility  of  associated  pelvic  and  appendicular  disease  must  not  be 
overlooked. 

(b)  Renal  causes. — Movable  kidney  with  Dietl's  crises,  renal  cal- 
culus, and  ureteral  calculus,  all  may  give  rise  to  symptoms  resembling 
acute  or  subacute  appendicitis.  The  character  and  position  of  the 
pain,  the  absence  of  fever  and  of  constipation,  the  examination  of  the 
urine,  and  X-ray  investigation  should  serve  to  eliminate  these  sources 
of  error. 

(c)  Hepatic  causes,  such  as  cholecystitis  and  cholelithiasis,  can 
generally  be  distinguished  by  the  position  of  the  tenderness,  a  history 
or  the  presence  of  jaundice,  and  the  radiation  of  the  pain  to  the 
shoulder.  Disease  of  a  subhepatic  appendix  may  simulate  affections 
of  the  gall-bladder  very  closely,  and,  on  the  other  hand,  a  large,  tender, 
low-lying  gall-bladder  has  been  mistaken  for  an  appendix  abscess. 

(d)  Gastric  and  duodenal  ulcer  are  to  be  excluded  by  inquiry  into 
the  relation  of  pain  to  ingestion  of  food,  and  the  absence  of  epigastric 
tenderness,  melaena,  hsematemesis,  and  gastric  dilatation. 

(e)  The  onset  of  pneumonia  and  of  pleurisy  occasionally  mimics 
appendicitis  by  causing  acute  abdominal  pain  and  rigidity.  A  care- 
ful examination  of  the  chest  should  prevent  error  in  such  cases. 

2.  Diagnosis  of  the  severity  and  degree  of  the  appen- 
dicitis.— At  the  onset  there  is  no  means  of  telling  whether  the  attack 
is  one  which  will  run  a  mild  course  and  subside  spontaneously,  or 


AGUTI-:    APPENDICITIS:   DIAGNOSIS  549 

whether  it   will  proceed  to  abscess  formation  or  the  involvement  of 

the  peritoneum  in  a  diffuse,  spreading  inflammation.     The  acutei 

of  tin'  unset  is  but  a  poor  indication  oi  the  probable  course  of  events, 
because  an  apparently  mild  attack  may  go  on  to  the  formation  <>f  an 
abscess,  or  may.  from  perforation  or  gangrene,  at  any  momenl  presenl 
the  mosl  urgent  symptoms  of  spreading  peritonitis. 

When  tin-  patient  has  not  been  seen  from  the  commencement  of  the 
attack,  and  the  course  has  been  so  atypical  that  the  disease  could  ool 
be  recognized  until  two  or  three  days  have  elapsed,  the  diagnosis  of 
the  degree  and  severity  of  the  appendicitis  becomes  a  matter  of  some 
difficulty.  In  watching  a  case  of  this  kind  so  that  surgical  treatment 
may  be  adopted  at  the  right  moment,  it  is  of  the  utmost  importance 
to  avoid  the  administration  of  morphia  or  opium,  since  these  drugs 
may  completely  obscure  symptoms  of  great  gravity.  The  presence 
of  a  definite  tumour,  felt  either  through  the  abdominal  wall  or  per 
rectum,  which  is  increasing  in  size,  or  at  least  not  diminishing,  after 
several  days  of  illness,  together  with  continued  fever  and  high  leuco- 
cytosis,  especially  if  accompanied  by  diarrhoea,  indicates  the  formation 
of  an  abscess.  At  this  stage  spontaneous  relief  may  occur  from  the  dis- 
charge of  pus  into  the  bowel.  This  would  be  indicated  by  the  passage 
of  pus  and  blood  per  rectum,  followed  by  a  fall  of  temperature  and  an 
amelioration  of  the  febrile  symptoms.  On  the  other  hand,  the  pus 
may  approach  the  surface,  when  the  abscess  will  be  felt  as  a  defi- 
nite rounded  tumour.  As  localization  becomes  more  complete,  toxic- 
absorption  diminishes,  so  that  even  without  evacuation  of  the  pus 
the  febrile  symptoms  in  such  cases  subside,  and  the  presence  of  a 
large  abscess,  full  of  the  most  evil-smelling  pus,  is  not  incompatible 
with  a  normal  temperature  and  a  clean  tongue.  -j 

The   symptoms    which    indicate    a    spreading    peritonitis    are    an 
accelerating  pulse-rate  and  a  subnormal  temperature,  vomiting,  "facies   I 
Hippocratica,"    and    increasing    abdominal    distension    and    rigidity./ 
Hiccup  is  a  symptom  of  grave  import. 

Treatment. — Many  'slight  attacks  of  acute  appendicitis  subside 
spontaneously,  but,  inasmuch  as  there  is  no  means  of  distinguishing 
these  cases  at  the  onset,  the  decision  to  postpone  operation  carries 
with  it  a  grave  responsibility.  With  cases  running  a  mild  course,  which 
are  not  seen  or  are  not  diagnosed  for  several  days,  and  in  which  opera- 
tion is  strongly  opposed  by  the  patient  or  his  friends,  non-operative 
treatment  may  be  adopted,  for  the  details  of  which  reference  must  be 
made  to  the  textbooks  of  Medicine.  The  main  points  in  the  treatment 
are  complete  rest  in  bed  until  alLpain  and  tenderness  have  disappeared, 
a  restricted  diet,  a  regular  action  of  the  bowels  secured  by  enemata 
and  mild  aperients,  fomentations  to  the  abdomen,  and  the  avoidance 
of  opium. 


55o  THE    APPENDIX 

Surgical  treatment  of  acute  appendicitis.— The  best  time 
for  operation  is  during  the  first  twenty-four  hours  of  the  attack,  and 
the  earlier  the  better.  The  advantages  are  obvious,  for  not  only  is 
the  mortality  in  this  stage  no  greater  than  that  of  "  interval "  appen- 
diecctomy,  but  the  patient  is  saved  from  the  risks  of  diffuse  peri- 
tonitis and  abscess  formation,  the  attack  is  cut  short,  and  the  abdo- 
minal wall  is  not  weakened  by  the  use  of  drainage  tubes. 

Cases  not  seen  or  not  recognized  until  the  third,  fourth,  or  fifth  day 
of  illness  present  greater  difficulty.  The  attack  may  then  be  about  to 
subside  ;  a  small  localized  periappendicular  abscess  may  have  opened 
into  the  bowel ;  or  the  appendix  may  be  deeply  situated  amongst 
adhesions  and  surrounded  by  a  small  localized  collection  of  pus,  the 
disturbance  of  which  might  possibly  prove  to  be  the  starting-point  of 
a  diffuse  peritonitis.  The  difficulty  of  decision  may  be  increased  by 
the  previous  administration  of  opium  ;  this  may  be  completely  mask- 
ing symptoms  which,  in  the  absence  of  this  disturbing  factor,  would 
indicate  immediate  operation,  such  as  vomiting,  increasing  distension 
and  rigidity,  and  an  accelerating  pulse-rate. 

The  operation  for  acute  appendicitis  within  the  first  few  hours  of 
the  onset  differs  in  no  essential  respect  from  that  of  an  interval 
appendicectomy,  provided  that  perforation  and  gangrene  have  not 
taken  place.  When  these  gross  changes  have  occurred,  as  they  occa- 
sionally do  even  at  so  early  a  stage,  the  operation  must  be  completed 
in  the  manner  described  under  the  next  heading. 

Treatment  of  acute  appendicitis  with  diffuse  peritonitis. 
— Immediate  operation  is  the  only  course  to  be  adopted,  for  the  delay 
of  even  two  or  three  hours  may  turn  the  scale  between  recovery  and 
death.  The  operation  embraces  two  essentials,  namely,  the  removal 
of  the  appendix  and  the  treatment  of  the  peritoneum.  These,  together 
with  the  after-treatment,  are  described  under  Peritonitis  (p.  569). 

The  mere  opening  and  draining  of  the  abdomen  in  the  right  iliac 
fossa  without  removal  of  the  appendix  has  been  recommended  in  the 
belief  that  in  desperate  cases  the  immediate  danger  is  thus  best  tided 
over.  Statistics  show  this  view  to  be  erroneous.  During  the  years 
1894  to  1903,  38  cases  were  so  treated  at  St.  Thomas's  Hospital, 
with  a  mortality  of  97 '3  per  cent.  Contrasted  with  this  result,  the 
operation  of  removal  of  the  appendix,  combined  with  some  attempt 
to  cleanse  the  peritoneum  during  the  same  period,  showed  a  mor- 
tality of  81  "2  per  cent.  These  cases  were  almost  all  subjected  to 
general  lavage  of  the  peritoneal  cavity,  a  procedure  which  is  now 
recognized  to  have  been  wrong,  and  which  doubtless  contributed 
towards  that  exceedingly  high  mortality.  Since  the  adoption  of 
strictly  local  treatment  of  the  peritoneum,  generally  by  dry  swabbing, 
the    death-rate   has    fallen    in    the   striking  manner  indicated  in  the 


APPENDIX   ABSCESS:   TREATMENT 


5j' 


chart  (Fig.  438).  The  figures  given  here  are  not  those  of  selected 
eases  df  spreading  peritonitis  in  an  early  stage,  but  they  embrace 
all  the  cases  admitted  to  hospital  with  diffuse  peritonitis,  however 

desperate,  which  were  subjected  to  operation. 

Treatment  of  appendicitis  with  local  abscess. — An  appen- 
dix abscess  must,  like  an  abscess  anywhere  else,  be  opened  as  soon 
as  a  diagnosis  has  been  arrived  at.  Delay  involves  greater  risks 
than  immediate  action, 
the  possible  results 
being  rupture  of  the 
abscess  into  the  general 
peritoneal  cavity,  into 
the  bowel,  or  into  the 
bladder ;  the  formation 
of  a  subphrenic  abscess  ; 
retroperitoneal  celluli- 
tis ;  and  the  formation 
of  dense  adhesions  which 
may  later  give  rise  to 
intestinal  obstruction 
and  other  troubles. 

The  incision  is  most 
conveniently  placed 
over  the  spot  at  which 
the  pus  is  judged  to 
be  closest  to  the  sur- 
face and  should  take 
the  form  of  a  muscle- 
splitting  operation.  For 
the  majority,  either 
McBurnev's  "  gridiron  " 


1834 

to 
1903 

1904 

I905 

1906 

1907 

1 908 

1909 

\ 

X                                                      i     -  - 

\ 

\ 

fl 

\ 

3 

-3 

o  50 

£ 

c 

O 
£    30 

>^                 >* 

i          | 

10 

1 

1 

1          1 

0 

Fig.  438. — Diagram  of  mortality  percentages 
in  operation  for  removal  of  the  appendix. 


opening,  or  an  opening  which .  separates  the  fibres  of  the  right  rectus 
muscle  below  the  umbilicus,  is  best ;  abscesses  situated  far  back  in 
the  loin  may  be  reached  through  a  "  split-muscle  "  opening  similar 
to  that  of  McBurney  ;  and  occasionally  it  is  advisable  to  open  the 
abscess  by  an  incision  through  the  posterior  vaginal  fornix.  In  a 
neglected  case  the  abdominal  wall  may  be  cedematous,  and  the  skin 
may  even  be  reddened  over  a  pointing  abscess,  so  that  the  pus  can 
be  reached  by  little  more  than  a  skin  incision.  In  others  the  parietal 
peritoneum  forms  part  of  the  abscess  wall,  so  that  the  pus  can  be  readily 
evacuated  without  opening  the  general  peritoneal  cavity.  In  most 
cases,  however,  the  peritoneal  cavity  is  opened  into  as  soon  as  the 
parietal  peritoneum  is  incised.  When  this  happens  the  general  cavity 
must  be  carefully  packed  off  with  gauze  strips  and  the  abscess  gently 


552  THE   APPENDIX 

opened  into  with  the  finger.  As  soon  as  the  pus  has  ceased  to  flow, 
one  or  more  large  rubber  tubes  are  inserted  into  the  abscess  cavity, 
and  the  wound  is  sutured  around  them.  The  gauze  strips  which  were 
used  to  shut  off  the  peritoneal  cavity  may  with  advantage  be  left 
in  situ  for  two  or  three  days. 

The  question  of  immediate  removal  of  the  appendix  is  one  that 
has  received  considerable  attention,  and  upon  which  different  sur- 
geons hold  different  views. 

According  to  the  St.  Thomas's  Hospital  statistics,  the  mortality  is 
practically  the  same  whether  the  appendix  is  removed  at  once  or  not. 

Clearly,  when  the  appendix  is  readily  felt  in  the  abscess  cavitj-,  and 
can  easily  be  removed  without  much  disturbance,  the  operation  should 
be  completed  in  one  stage,  because  the  illness  is  thereby  shortened, 
and  the  patient  is  saved  the  necessity  of  a  subsequent  operation.  But 
if  the  appendix  is  not  found  at  once,  it  is  probable  that  the  patient's 
interests  are  best  served  by  making  no  deliberate  search  for  it,  but 
leaving  its  removal  to  be  effected  at  a  second  operation  some  weeks 
later.     The  mortality  of  cases  of  appendix  abscess  is  about  15  per  cent. 

That  the  appendix  ought  to  be  removed  subsequently  is  now  almost 
universally  admitted.  There  is  no  evidence  to  support  the  old  belief 
that  an  attack  of  appendicitis  which  ends  in  suppuration  is  curative, 
and  that  no  further  trouble  is  likely  to  occur.  All  the  available  evidence 
points  in  the  opposite  direction.  Recurrent  attacks  of  acute  appen- 
dicitis and  recurrent  abscesses  are  common,  and  even  acute  attacks, 
with  diffuse  and  fatal  peritonitis,  are  occasionally  encountered.  The 
St.  Thomas's  Hospital  series  contains  detailed  descriptions  of  49 
appendices  removed  at  periods  varying  from  two  to  twelve  months 
after  recovery  from  an  abscess.  In  no  single  instance  was  the  appen- 
dix obliterated ;  44'9  per  cent,  showed  well-marked  constrictions. 
27 "5  per  cent,  the  healed  scars  of  previous  perforation,  16"3  per  cent, 
contained  one  or  more  concretions,  10 '2  per  cent,  were  cystic  and 
contained  pus,  14*2  per  cent,  were  large  and  greatly  thickened,  204 
per  cent,  were  free  from  adhesions,  61  per  cent,  were  "  catarrhal  " 
or  "  practically  normal,"  and  4-l  per  cent,  contained  unhealed  ulcers. 
The  conclusion  arrived  at  from  a  critical  study  of  the  1,075  cases  in 
this  series  was,  that  of  the  subjects  of  appendix  abscess  in  whom  the 
appendix  is  not  removed,  a  minimum  of  10  per  cent,  will  suffer  from 
further  serious  trouble. 

B.  CHRONIC  AND  RELAPSING  APPENDICITIS 
The  term  "  relapsing  appendicitis  "  is  used  to  describe  those  cases 
in  which  there  are  recurring  attacks  of  an  acute  or  chronic  character. 
Each  individual  attack  comes  into  its  own  particular  category,  and 
is  more  often  of  a  subacute  or  chronic  nature. 


CHRONIC    APPENDICITIS  553 

Chronic  appendicitis  includes  cases  in  which  a  pathological  con- 
dition of  the  appendix  gives  rise  t<>  a  variety  of  mure  or  less  vague 
abdominal   symptoms.     "Appendicular  colic"   may  conveniently  be 

included  in  this  class.  By  it  is  meant  an  attack  of  abdominal  pain, 
more  or  less  severe,  with  <>r  without  vomiting,  unaccompanied  by 
lexer,  lasting  but  a  few  minutes  or  hours,  and  having  a  great  tendency 
to  recur  at  intervals.  Such  attacks  are  ascribed  to  temporary  kink- 
ing  and  distension  of  the  appendix,  to  obstruction  of  its  lumen  by 
stricture,  or  bo  attempts  bo  extrude  a  concretion.  Exactly  how  such 
attacks  are  caused,  how  far  they  are  related  to  definite  structural 
changes  in  the  appendix,  and  what  is  their  relation  to  appendicitis. 
are  matters  of  speculation.  Naturally,  a  diagnosis  of  appendicular 
colic  would  be  made  only  with  the  greatest  caution,  and  after  the  most 
careful  exclusion  of  other  causes  of  similar  abdominal  pain,  such  as 
renal  colic. 

A  large  number  of  different  symptoms  are  ascribed  to  chronic 
disease  of  the  appendix.     Among  these  may  be  mentioned — 

1.  More  or  less  persistent  abdominal  discomfort,  increased  by 
exertion  or  constipation,  and  not  necessarily  referred  to  the  right  iliac 
region. 

i*.  Attacks  of  "  appendicular  colic." 

3.  Chronic  constipation  and'  anaemia. 

■i.  Chronic  diarrhoea  and  some  forms  of  colitis. 

5.  Chronic  "  dyspepsia,"  and  even  hsematemesis,  melsena,  and 
"*  hunger  pain." 

The  diagnosis  of  chronic  appendicitis  ought  never  to  be  made 
hastily  and  without  due  consideration  of  the  many  other  conditions 
which  may  give  rise  to  similar  symptoms.  Affections  of  the  ovary 
and  Fallopian  tube  must  be  eliminated  by  careful  bimanual  pelvic 
examination;  renal  and  ureteral  calculus  by  the  X-rays  and  the 
examination  of  the  urine,  but  remembering  that  concretions  in  the 
appendix  have  sometimes  been  demonstrated  by  the  X-rays.  Nephrop- 
tosis often  causes  considerable  difficulty,  and  the  coexistence  of  a 
movable  kidney  and  a  diseased  appendix  may  necessitate  diagnosis 
by  exploratory  laparotomy,  followed  by  both  appendicectomy  and 
nephropexy.  Chronic  disease  of  the  appendix  may  give  rise  to  many 
of  the  symptoms  of  gall-stones,  cholecystitis,  and  duodenal  ulcer,  so 
that  in  difficult  cases  the  diagnosis  has  to  be  made  by  exploratory 
operation. 

AVhen  a  palpable  tumour  is  present  in  the  region  of  the  appendix, 
and  more  or  less  vague  abdominal  symptoms  are  complained  of,  the 
probability  of  the  case  being  one  of  chronic  appendicitis  is  great,  yet 
several  other  conditions  can  give  rise  to  identical  symptoms  and  signs. 
Amongst  these  the  chief  are  tuberculosis,  actinomycosis,  and  carcinoma 


554  THE   APPENDIX 

of  the  caecum,  chronic  eaecal  intussusception,  tuberculous  peritonitis, 
tuberculous  mesenteric  glands,  and  sarcoma  of  the  ventral  aspect  of 
the  ilium.  The  differential  diagnosis  of  these  conditions  is  not  always 
possible  without  an  abdominal  exploration. 

Appendicectomy. — The  removal  of  the  appendix  in  the  quiet 
period  is  an  operation  which  is  practically  devoid  of  danger  to  life, 
and,  if  properly  performed,  is  without  risk  of  subsequent  weakness  of 
the  abdominal  wall.  Xo  special  preparation  is  needed  beyond  the 
customary  emptying  of  the  bowels  by  enema  on  the  morning  of  the 
operation,  and  the  shaving  and  thorough  cleansing  of  the  skin  at  and 
around  the  site  of  the  operation. 

The  method  of  entering  the  abdominal  cavity  is  a  matter  of  great 
importance.  Formerly  the  incision  was  made  either  directly  through 
the  muscles,  or  through  the  semilunar  line  ;  both  these  methods  have 
rightly  been  abandoned  by  nearly  all  surgeons  at  the  present  day. 
as  almost  inevitably  being  followed  by  a  postoperative  ventral 
hernia. 

The  method  of  splitting  the  right  rectus  muscle  in  the  direction  of 
its  fibres  has  been  referred  to  in  dealing  with  acute  appendicitis  ;  there 
it  possesses  certain  advantages  which  do  not  necessarily  hold  good 
in  the  case  of  an  interval  operation  for  appendicectomy. 

There  are  two  chief  methods,  namely,  the  "  gridiron "  incision  of 
McBurney,  and  the  temporary  displacement  of  the  rectus  muscle  de- 
vised by  W .  H.  Battle.  In  the  former  the  skin  incision  crosses  the 
spino-umbilical  line  at  a  point  If  in.  from  the  antero-superior  iliac 
spine,  and  is  made  to  divide  the  aponeurosis  of  the  external  oblique 
in  the  same  direction  and  for  the  same  distance.  Ketractors  are 
employed  to  spread  the  skin  and  aponeurosis  apart  as  widely  as  pos- 
sible, and  the  fascia  covering  the  internal  oblique  is  divided  at  right 
angles  to  the  first  incision.  The  knife  is  then  laid  aside,  and  by  blunt 
dissection  the  internal  oblique  and  transversalis  abdominis  muscles 
are  split  in  the  direction  of  their  fibres,  which  at  this  point  is  as  nearly 
as  possible  identical.  The  transversalis  fascia  is  thus  exposed,  and, 
together  witli  the  peritoneum,  is  divided  in  a  direction  parallel  with 
the  skin  incision.  Battle's  incision  crosses  the  spino-umbilical  line 
at  right  angles  near  its  middle,  and  exposes  the  anterior  layer  of  the 
rectus  sheath,  which  is  then  divided  a  little  internally  to  the  skin 
incision  and  in  the  same  direction.  The  outer  border  of  the  rectus 
muscle  is  now  freed  and  drawn  inwards  with  a  retractor.  The  pos- 
terior laver  of  the  rectus  sheath,  together  with  the  underlving  peri- 
toneum, is  next  divided  either  vertically  or  transversely,  care  being 
taken  to  avoid  division  of  the  motor  nerves  to  the  rectus,  which  arc 
readily  identified  as  soon  as  the  muscle  has  been  drawn  aside. 

Both  these  incisions  are  useful,  and  are  followed  by  no  weakness  of 


APPENDICECTOMY  555 

the  abdominal  wall,  but  Battle's  has  this  advantage  over  McBurney's, 
namely,  thai  it  ran  be  extended  upwards  and  downwards  if  the  exigen- 
cies of  any  particular  case  require  a  larger  abdominal  opening,  whereas 
the  additional  room  which  can  be  obtained  in  Mr  Burner's  incision 
by  firm  retraction  is  very  small.  Since  it  is  never  possible  to  be  sure 
beforehand  whether  the  identification  and  separation  of  the  appendix 
will  be  easy  or  difficult,  Battle's  incision  is  the  more  generally  useful. 
Whichever  abdominal  incision  is  adopted,  the  first  care  of  the  sur- 
geon on  opening  the  peritoneum  is  to  ascertain  the  position  of  the 
appendix.  As  a  rule,  the  caecum  first  comes  into  view,  and  then  it 
is  an  easy  matter  to  find  the  appendix  by  following  down  wards  the 
anterior  muscle-band  of  the  caecum.  Any  adhesions  which  may  be 
present  are  next  carefully  separated,  and  the  appendix  is  brought  out 
of  the  wound  and  isolated  from  the  peritoneal  cavity  with  strips  of 
gauze.  The  mesoappendix  having  been  ligatured  and  divided,  the 
little  process  is  ready  for  amputation.  Innumerable  details  of  tech- 
nique have  been  devised,  most  of  which  are  perfectly  satisfactory. 
Probably  the  two  methods  most  frequently  adopted  in  this  countrv 
are  Barker's  "  cuff  "  method  and  Kocher's  "  clamp  "  method.  In  the 
former  the  peritoneum  is  divided  about  a  quarter  of  an  inch  from  the 
base  of  the  appendix,  and  turned  back  towards  the  caecum.  The  rest 
of  the  appendix  is  ligatured  and  cut  away,  the  stump  being  touched 
with  a  drop  of  pure  carbolic  acid.  The  little  cuff  of  peritoneum  is  then 
used  to  cover  in  the  stump.  In  the  latter  method  a  strong  crush- 
ing clamp  is  applied  to  the  base  of  the  appendix  close  to  the  caecum. 
This  instrument  divides  the  inner  coats,  which  retract  in  either  direc- 
tion, leaving  a  flat  band  of  crushed  peritoneum  which  can  be  divided 
without  opening  the  lumen  of  the  appendix  at  all.  This  band  is  liga- 
tured and  divided,  and  the  tiny  stump  is  invaginated  into  the  caecal 
wall  with  a  single  purse-string  suture.  When  the  appendix  is  inflamed 
and  swollen,  the  clamp  method  is  unsatisfactory,  as  the  instrument 
is  often  found  to  shear  the  appendix  across. 

RARE  DISEASES  OF  THE  APPENDIX 

Diseases  of  the  appendix  other  than  those  due  to  pyogenetic  bac- 
teria are  rare,  and  still  more  rarely  do  they  cause  symptoms  inde- 
pendently of  secondary  infection.  It  is  usually  a  superadded  acute 
inflammation  which  directs  attention  to  the  appendix,  and,  as  a  rule, 
the  tumour  or  other  rare  condition  is  discovered  accidentally  when 
the  appendix  is    removed. 

TUMOURS 

Although  very  rare,  primary  appendicular  tumours  are  probably 
sometimes  overlooked,  owing  to  their  small  size  and  freedom    from 


55<i  THE   APPENDIX 

recognizable  symptoms  or  to  involvement  in  the  necrosis  of  the 
appendix. 

Innocent  tumours  are  mere  pathological  curiosities.  Up  to  1906 
Rolleston  and  Lawrence  Jones  found  42  undoubted  records  of  primary 
malignant  growth  starting  in  the  appendix,  of  which  37  were  carcinoma. 
3  endothelioma,  and  2  sarcoma.  The  size  varied  from  that  of  a  pea  to 
that  of  a  marble,  and  in  nearly  half  the  cases  the  growth  was  situated 
in  the  distal  third  of  the  appendix.  Metastatic  growths  are  recorded 
as  having  been  present  in  only  12  per  cent.  The  average  age  of  the 
patients  was — for  the  carcinomas  30'6  years,  for  the  endotheliomas 
30'3  years,  and  for  the  sarcomas  39  years,  the  average  being  thus 
lower  than  that  for  carcinoma  in  other  parts  of  the  intestinal  tract 
by  17  years. 

The  commonest  type  is  represented  by  a  small,  white,  firm  growth 
consisting  of  polyhedral  or  spheroidal  cells  showing  an  alveolar  arrange- 
ment, and  often  exhibiting  vacuolation.  The  commoner  type  of  car- 
cinoma of  the  appendix  differs,  therefore,  from  the  common  type  of 
carcinoma  of  the  alimentary  canal  elsewhere  in  being  spheroidal- 
celled  instead  of  columnar-celled.  These  spheroidal- celled  growths  are 
also  comparatively  benign  in  their  clinical  character.  In  no  case  was 
a  diagnosis  made  before  operation,  and  the  reasons  which  led  to  the 
operation  were  either  symptoms  of  acute,  chronic,  or  recurrent  appen- 
dicitis, symptoms  referable  to  the  female  pelvic  organs,  or  persistent 
fistula  following  abscess  in  the  right  iliac  fossa. 

Secondary  involvement  of  the  appendix  in  malignant  growths  of 
the  caecum  and  other  parts  is  less  uncommon.  In  a  series  of  3,770 
autopsies  mentioned  by  Kelly,  there  was  not  a  single  example  'of 
primary  tumour  of  the  appendix,  but  there  were  11  cases  in  which 
the  organ  was  secondarily  involved  in  malignant  growth — 10  times 
by  carcinoma,   and  once  by  sarcoma. 

TUBERCULOSIS 

While  the  appendix  is  not  infrequently  involved  secondarily  in 
tuberculous  disease  arising  in  the  ileo-caecal  region,  or  from  a  tuber- 
culous ovary  or  Fallopian  tube,  it  is  rarely  the  primary  seat  of  the 
disease  ;  even  then  it  gives  rise  to  no  symptoms  by  which  it  can  be 
recognized  clinically. 

In  2,000  autopsies  upon  patients  who  had  died  of  tuberculosis, 
Fenwick  and  Dodwell  found  17  cases  in  which  the  intestinal  ulceration 
was  limited  to  the  appendix. 

ACTINOMYCOSIS 

Abdominal  actinomycosis  is  most  often  found  in  the  caecal  region, 
and  in  several  reported  cases  there  is  no  doubt  that  the  appendix  was 


RARE    DISEASES  OF   THE    APPENDIX  557 

the  Beat  <>f  the  primary  disease.     The  Btreptothrix  bas  been  demon- 
Btrated  in  the  appendix,  and  more  than  once  in  company  with  ;i  sprain 
of  corn.     The  pathology  of  the  disa  se  differs  in  no  essential  resp 
from  thai  of  actinomycosis  elsewhere.     (For  IIi-o-C.'mtmI  Aetinoniveo 
m    V6L  I.,  p.  3' 

[NTUSSUSi  EPTION,  BERNIAS,  INTESTINAL  OBSTRUCTION 

The  appendix  is  almost  necessarily  involved  in  intussusceptions 
of  the  cecal,  ileo-csecal,  and  ileo-colic  varieties,  and  is  prone  to  have 
its  vascularity  gravely  interfered  with  thereby.     On  reducing  such  an 

intussusception,  it  is  sometimes  advisable  to  amputate  the  appendix, 
even  though  the  little  extra  time  required  may  add  to  the  patient's 
danger. 

Primary  intussusception  or  inversion  of  the  appendix  itself  is 
bur  Battle  and  Corner  have  succeeded  in  collecting  17  cases  from 
the  literature.  It  is  suggested  that  in  the  attempt  to  extrude  a  con- 
cretion the  mucous  membrane  becomes  prolapsed  into  the  caecum,  and 
that  this  is  followed  by  inversion  of  the  caecum  and  then  of  the  ascend- 
ing colon,  so  that  a  complicated  form  of  intussusception  is  produced. 

Involvement  in  hernias  has  been  already  alluded  to  (p.  540). 
According  to  Kelly,  the  appendix  is  present  in  from  1  to  2  per  cent, 
of  all  hernias.  A  large  proportion  of  the  cases  occurs  in  infants,  when 
the  appendix  can  sometimes  be  felt  in  the  hernia  as  a  rounded  cord. 
It  is  commonly  adherent,  at  any  rate  in  the  cases  which  are  operated 
upon,  and  in  congenital  inguinal  hernia  has  been  found  adherent  to 
the  testis.  In  hernial  sacs  the  appendix  has  been  found  strangulated, 
inflamed,  and  perforated  ;  and  in  this  connexion  an  interesting  point 
has  been  noted  by  Battle  and  Corner,  namely,  that  when  strangulated 
in  a  hernia  the  appendix  is  more  often  found  alone  than  in  company 
with  other  viscera. 

Intestinal  obstruction  is  sometimes  produced  by  the  incar- 
ceration of  a  coil  of  intestine  beneath  a  band  formed  by  the  adherent 
appendix. 

BIBLIOGRAPHY 

Battle  and  Corner,  Surgery  of  the  Diseases  of  the  Appendix.     London,   1 1'< »4 . 

Cushing,  Harvey,  Johns  Hopkins  Hosp.  Bepts.,  1904,  vol.  viii. 

Dudgeon  and  Sargent,  Bacteriology  of  Peritonitis.     London,  1905. 

Fenwick  and  Dodwell,  Lancet,  1894. 

Hawkins,  H.  P.,  Diseases  of  the  Vermiform  Appendix.     London,  1895. 

Macewen.  Sir  W.,  Lancet,  Oct.  8.  1904. 

Poirier  and  Cuneo,  The  Lymphatics.    London,  1903. 

Robinson,  Byrom,  quoted  by  Battle  and  Corner. 

Rolleston  and  Lawrence  Jones,  Med.-Chir.  Trans.,  London,  lxxxix.  125. 

Sargent,  Percy,  Lancet,  Sept.,  1905. 

Still,  G.  F.,  Brit.  Med.  Journ.,  April  15,  1899. 

Tavel  and  Lanz,  /.'•  v.  ie  Chir.,  Paris,  1904. 

Veillon  and  Zuber,  Arch,  dc  Med.  Exper.,  July,  1898. 

Wallace  and  Sargent,  St.  Thomas's  Hosp.  Repts.,  1904. 


THE   PERITONEUM 

By    PERCY  SARGENT,   M.A.,   M.B.,   B.C.Cantab., 
F.R.C.S.Eng. 

Anatomy  and  physiology. — The  peritoneum  is  a  thin,  smooth, 
elastic  membrane  consisting  of  a  layer  of  flattened  endothelial  cells 
resting  upon  a  layer  of  subendothelial  connective  tissue.  This  mem- 
brane lines  the  walls  of  the  abdominal  cavity  (parietal  layer),  and 
covers  with  a  varying  degree  of  completeness  the  abdominal  and 
pelvic  viscera  (visceral  layer).  Its  superficial  area  is  stated  to  equal 
that  of  the  skin.  Outside  the  peritoneal  membrane  proper  is  the 
subperitoneal  connective  tissue,  which,  in  certain  situations,  is 
heavily  loaded  with  fat. 

The  so-called  peritoneal  cavity  is  only  a  potential  space,  for  its 
smooth  opposing  surfaces  are  everywhere  in  contact,  being  separated 
in  health  only  by  a  minimal  amount  of  lubricating  fluid.  It  is  only 
by  artificial  or  accidental  separation  of  these  opposing  surfaces  that 
a  cavity  is  produced. 

In  the  male  the  peritoneum  forms  a  completely  closed  sac  ;  in  the 
female  the  interior  of  the  Fallopian  tube  communicates  directly  with 
the  interior  of  the  potential  peritoneal  cavity  through  a  minute  orifice — 
the  ostium  abdominale. 

Peritoneal  compartments  and  pouches. — Anatomists  divide 
the  peritoneal  sac  into  two  main  compartments,  the  greater  and  the 
lesser,  communicating  with  one  another  by  a  narrow  passage,  the  walls 
of  which  are  normally  in  contact  with  one  another.  This  is  the  fora- 
men of  Winslow,  which  is  situated  at  the  right  side  of  the  first  lumbar 
vertebra  close  to  the  neck  of  the  gall-bladder.  The  greater  sac  is 
further  subdivided,  from  clinical  considerations,  into  certain  areas 
into  which  fluids  tend  to  gravitate  ;  these  very  readily  become  shut 
off  into  more  or  less  definite  compartments  by  the  agglutination  of 
neighbouring  areas  of  peritoneum. 

With  the  body  supine,  the  lumbar  spine  presents  a  well-marked  for- 
ward projection  with  a  deep  fossa  on  either  side.  A  similar  projection 
is  afforded  by  the  pelvic  brim  and  the  superjacent  psoas  muscles.     To 

558 


"  PERITONEAL    \\  A  II  KSI I  EI  )S  " 


559 


theso  projections,  which  play  bo  importanl  a  part  in  directum  the 
eourso  of  fluid  effusions,  C.  R.  Box  has  given  tin-  n;imo  of  abdominal 
watersheds  (Figs.  439  and  440). 

There  are  thus  three  large  wells  into  which  fluids  tend  to  gravi- 
tate, namely,  the  pelvic  cavity  and  the  right  and  left  lumbar  regions. 
But  the  course  which  effused  fluid  takes  is  further  influenced  by  the 
arrangement  of  certain  peritoneal  folds  and  <>[  the  fixed  portions  of 


Figs.  439  and  440. — Diagrams  to  show  the  "peritoneal  watersheds." 
(C.  R.  Box.)     (See  text.) 

the  intestine.  "  Thus  the  transverse  mesocolon  and  great  omentum, 
passing  across  the  belly  cavity,  mark  off  an  upper  from  a  lower  terri- 
tory, which  communicate  with  one  another  only  in  the  lumbar  regions. 
This  partition  is  more  complete  on  the  left  than  the  right  side,  especi- 
ally when  the  phrenicocolic  fold  of  peritoneum,  which  passes  from 
the  left  end  of  the  transverse  colon  to  the  diaphragm  below  the  spleen, 
is  well  marked.  A  similar  fold  is  sometimes  present  on  the  right 
side."     (C.  R.  Box.) 

Above  this  transverse  mesocolic  shelf,  and  on  the  right  slope  of 
the  vertebral  watershed,  lie  the  pylorus,  the  commencement  of  the 
duodenum,  the  gall-bladder,  and  the  right  lobe  of  the  liver ;  in  a 
similar  position  on  the  left  side  lie  the  stomach  and  spleen.  Effusions 
resulting  from  the  perforation  or  inflammation  of  these  structures  will 


56o  THE   PERITONEUM 

consequently  be  directed,  in  the  one  case  towards  the  right  kidney, 
and  in  the  other  towards  the  spleen. 

Near  the  summit  of  the  pelvic  ridge  on  the  right  side  the  appendix 
often  lies,  so  that  a  purulent  effusion  resulting  from  a  diseased  appen- 
dix, if  it  does  not  gravitate  towards  the  pelvic  cavity,  is  directed 
upwards  alongside  the  colon  towards  the  right  renal  or  subhepatic 
pouch.  From  the  arrangement  both  of  the  watersheds  and  of  the 
peritoneal  folds,  together  with  the  anatomical  disposition  of  the  viscera 
which  are  most  frequently  the  source  of  intraperitoneal  effusion,  namely 
the  appendix,  pylorus,  duodenum,  and  bile  passages,  it  will  be  seen 
that  the  right  renal  pouch  is  a  region  of  great  clinical  importance.  The 
boundaries  of  this  pouch  are  :  "  above  and  in  front,  the  right  lobe 
of  the  liver  and  its  ligaments ;  below,  the  hepatic  flexure*  of  the  colon 
and  its  attachment  to  the  posterior  abdominal  wall ;  internally,  the 
peritoneum  covering  the  descending  duodenum  and  the  lumbar  spine, 
and  stretching  forwards  to  the  foramen  of  Winslow  ;  externally,  tke 
parietal  peritoneum  of  the  lumbar  region." 

The  subphrenic  region  is  also  of  special  importance.  A  subphrenic 
abscess  on  the  left  side  lies  between  the  spleen,  stomach,  and  left  lobe 
of  the  liver  on  the  one  hand,  and  the  diaphragm  on  the  other,  berno 
separated  by  the  diaphragm  from  the  lower  border  of  the  lung,  the 
pleural  cavity,  and  the  chest  wall ;  below,  it  is  limited  by  the  phrenico- 
colic  fold,  and  to  the  right  by  the  falciform  ligament.  Similarly,  a 
right-sided  subphrenic  abscess,  lying  between  the  right  dome  of  the 
diaphragm  and  the  liver,  may  be  limited  leftwards  by  the  falciform 
ligament. 

There  are,  in  addition,  certain  smaller  pouches  which  may  become 
the  seat  of  internal  hernias,  the  chief  of  which  are  the  paraduodenal, 
superior  duodenal,  and  inferior  duodenal  fossae  at  the  left  side  of  the 
2nd  lumbar  vertebras  ;  the  retrocolic,  ileo-ceecal,  and  ileo-colic  fossae 
in  the  right  iliac  fossa  ;  and  the  fossa  intersigmoidea  close  to  the  left 
sacro-iliac  joint,  marking  the  position  at  which  the  ureter  crosses  the 
external  iliac  artery.     None  of  these  fossae  is  of  constant  occurrence. 

Lymphatics. — There  is  no  direct  communication  between  the  peri- 
toneal cavity  and  the  lymphatic  system,  though  fluids  and  solid  par- 
ticles are  readily  removed  from  the  peritoneal  cavity  into  the  lymphatics; 
There  are  no  "  stomata  "  between  the  endothelial  cells,  nor,  over  the 
greater  part  of  the  peritoneal  membrane,  are  there  any  subendothelial 
lymphatic  spaces.  The  diaphragmatic  peritoneum,  however,  presents 
a  vast  number  of  pits  or  wells,  penetrating  between  the  tendon  bundles, 
which  are  microscopic  diverticula  of  the  peritoneum,  and,  like  it,  are 
lined  in  their  whole  extent  by  endothelial  cells. 

The  peritoneal  cavity  is  very  intimately  related  with  the  subpieural 
diaphragmatic   lymphatics,    which   present,   according  to   MacCalium, 


FUNCTIONS   OF  THE   PERITONEUM  561 

a  network  of  branching  lymphatic  trunks,  whose  efferent  vessels  pass 
to  the  mediastinal  and  abdominal  lymphatic  glands.  From  these 
lymphatic  vessels  diverticula  or  pouches  pass  downwards  through  the 
muscular  and  tendinous  tissue  of  the  diaphragm,  where  they  come 
into  the  most  intimate  relation  with  the  peritoneum,  being  only 
separated  from  it  by  a  delicate  basement  membrane.. 

Nerves. — Ramstrom  has  shown  by  dissection  the  ramifications  of 
the  lower  intercostal  nerves  in  the  serous  covering  of  the  abdominal 
wall.  Whilst  the  parietal  peritoneum  is  said  to  be  sensitive,  the  visceral 
portion  is  devoid  of  sensation  both  in  health  and  in  disease  (Gushing 
and  Lennander).  The  nerves  are  derived  from  the  same  source 
whence  arises  the  cutaneous  and  muscular  supply  of  the  abdominal 
wall,  namely j  the  last  seven  thoracic  trunks  ;  this  fact  accounts  for  the 
reflex  muscular  rigidity  and  the  superficial  tenderness  in  peritonitis. 

Functions  of  the  peritoneum. — In  health  the  peritoneum 
serves  to  permit  the  intestinal  and  other  intra-abdominal  movements 
to  take  place  painlessly  and  with  a  minimal  amount  of  friction.  Its 
various  folds  attach  the  viscera  to  one  another  and  to  the  parietes, 
and  also  serve  to  carry  the  blood-vessels  and  other  structures  from 
the  abdominal  wall  to  the  viscera. 

The  great  omentum  has  special  functions.  In  addition  to  that  ot 
protection,  fat  storage,  and  the  part  which,  in  injury  and  disease,  if 
is  able  to  play  in  sealing  an  accidental  opening  in  the  bowel  or  in  the 
abdominal  wall,  it  takes  a  special  share  in  the  disposal  of  bacteria 
>aad  other  solid  substances  which  may  find  their  way  into  the  peri- 
toneal cavity  (H.  E.  Durham  ;  Dudgeon  and  Ross). 

The  absorptive  powers  of  the  peritoneum  are  very  great,  and  both 
fluids  and  solid  particles  such  as  bacteria  are  removed  from  the 
peritoneal  cavity  with  great  readiness  and  rapidity.  The  fluids  are 
mainly  taken  up  by  the  lymphatics,  but  may  also,  when  under  pres- 
sure, pass  directly  into  the  blood-vessels  ;  the  solid  particles  are  removed 
by  the  lvmphatics  alone,  provided  that  the  membrane  is  intact.  This 
lymphatic  absorption  occurs  only  over  the  diaphragm  and  omentum, 
and  the  removal  of  solid  particles  takes  place  chiefly  by  phagocytosis, 
the  particles  being  carried  first  into  the  pits  described  above,  and  thence 
into  the  subperitoneal  lymphatic  vessels  and  spaces  (Muscatello). 

The  experiments  of  Buxton  and  Torrey  and  others  have  shown  that 
inert  particles  and  bacteria  also  find  their  way  into  the  lvmphatics 
without  the  aid  of  phagocytosis ;  and  Muscatello  thinks  that  the 
passage  of  the  phagocytes  leaves  minute  apertures  through  which 
particles  can  afterwards  be  drawn  by  the  suction  action  of  the  dia- 
phragm and  its  lymphatic  currents. 

Absorption  from  the  peritoneal  cavity  is  normally  aided  by  the 
pressure  of  the  continual  respiratory  movements  of  the  abdominal 
•2  k 


562  THE   PERITONEUM 

walls,  the  suction  action  of  the  diaphragm,  and  the  peristaltic  move- 
ments of  the  intestines.  In  disease  other  factors  come  into  play,  some 
hindering  and  others  assisting  absorption. 

Amongst  the  chief  additional  factors  which  assist  absorption  are — 
(1)  phagocytosis,  (2)  increased  intra-abdominal  pressure,  (3)  endo- 
thelial exfoliation. 

Those  which  diminish  absorption  are — (1)  diminution  of  respira- 
tory movements,  (2)  diminution  of  peristalsis,  (3)  fibrinous  deposi- 
tion upon  the  peritoneal  surface,  (4)  agglutination  of  intestinal  coils 
and  omentum,  (5)  lowering  of  intra-abdominal  pressure  by  lapar- 
otomy, (6)  toxeemic  fall  in  blood  ■  pressure. 

Defences  of  the  peritoneum  against  bacterial  infection. — 
The  introduction  of  foreign  matter,  whether  sterile  or  not,  is  the 
signal  for  the  appearance  in  the  peritoneal  cavity  of  an  effusion  of 
fluid  rich  in  leucocytes,  their  number  varying  with  the  nature  of  the 
foreign  matter.  Any  lesion  of  a  peritoneum-covered  organ,  such  as 
the  strangulation  of  a  coil  of  intestine,  inflammation  of  the  appendix, 
or  the  twisting  of  the  pedicle  of  an  ovarian  cyst,  is  rapidly  followed 
by  the  appearance  in  the  fluid  of  a  white  staphylococcus  of  extremely 
low  pathogenetic  properties  (Dudgeon  and  Sargent) ;  with  its  appear- 
ance the  exudate  becomes  rich  in  leucocytes,  and  it  is  upon  the  phago- 
cytic action  of  these  white  cells,  assisted  by  the  body  fluids,  that  the 
removal  of  the  pathogenetic  organisms  chiefly  depends.  If  this  defen- 
sive reaction  has  time  to  become  well  marked  before  any  large  quantity 
of  infective  material  has  gained  access  to  the  peritoneal  cavity,  the 
peritonitis  which  has  started  at  the  point  of  entrance  of  the  infection 
may  be  stopped  from  becoming  diffused  over  a  fatally  large  area,  either 
by  complete  absorption  or  by  loculation  of  the  effusion.  This  shutting- 
off  process  is  brought  about  by  the  gluing  together  of  adjacent  peri- 
toneal areas  with  a  plastic  exudate,  and  is  assisted  by  the  diminution 
of  respiratory  and  peristaltic  movements.  The  fibrinous  deposit  upon 
the  peritoneal  surface  also  serves  to  limit  the  absorption  of  toxins  into 
the  subendothelial  blood-vessels,  and  to  entangle  and  hold  harmless  a 
certain  amount  of  the  foreign  matter  until  such  time  as  it  can  be 
gradually  and  safely  removed  by  phagocytosis.     (Plate  98.) 

INJURIES  OF  THE  PERITONEUM 

1.  WOUNDS    AND    CONTUSIONS 

The  peritoneum  is  rarely  injured,   either  in  open  wounds  or 
contusions,   sufficiently  to  cause  clinical  symptoms  apart  from 
comitant  damage  to  the  abdominal  viscera.    The  visceral  injury  at 
overshadows  that  of  the  peritoneum  ;    later  the  resulting  peritonitis 
becomes  the  predominant  feature.     Contusions  of,   and  haemorrhagf 


Fig.  1. — Section    of   intestine    from  a  case  of   peritonitis    of   sixteen    hours'  duration. 

showing  inflammatory  deposit  which  becomes  less  as  the  mucous  coat    is  approached. 

("  B  "  eyepiece:    |  obj.) 


'*>, 


- 


2.  -Section   of  diaphragm,   showing  organization   of  fibrinous  deposit  in   a   case  of 
chronic  septic  peritonitis.     ('*  B  "  eyepiece;     ,  obj.) 


PLATE  98. 


1M  KITONEAL   INJURIES  563 

into,  the  mesentery  may,  in  tin-  absence  of  other  intra-abdominal 
injury,  cause  serious  symptoms,  and  even  lead  to  an  abdominal  explora- 
tion. Laceration  of  the  mesentery  or  omentum  alone  is  1 '-sponsible 
for  a  certain  number  of  cases  of  intraperitoneal  haemorrhage. 

Clean  wounds  of  the  pcritoin  u m  heal  with  greal  readiness;  infected 
wounds  also  heal  readily  if  the  virulence  and  number  of  the  bacteria 
introduced  are  not  beyond  the  very  considerable  defensive  powers  of 
the  peritoneum.  It  is,  indeed,  this  property  of  rapid  healing  which  per- 
mits of  anastomotic  operations  being  safely  performed  upon  the 
stomach  and  intestines.  The  omentum  plays  an  important  part  in 
abdominal  injuries.  It  may  become  rolled  around  and  isolate  infec- 
tive material,  and  may  even  prevent  leakage  from  a  perforated  organ 
by  becoming  adherent  to  and  sealing  the  opening.  It  also  possesses 
the  special  property  of  dealing  with  bacteria  by  phagocytosis  upon  its 
surface,  of  which  mention  has  already  been  made. 

2.  INTRAPERITONEAL   HAEMORRHAGE 

Traumatic  intraperitoneal  haemorrhage  may  take  place  from  torn 
or  incised  mesenteric  or  omental  vessels  without  any  visceral  injury. 
The  results  which  follow  such  haemorrhage  vary  with  the  quantity 
of  blood  effused,  and  may  be  summarized  as  follows :  (a)  Death 
from  loss  of  blood  alone ;  (b)  diffuse  peritonitis ;  (c)  formation  of  a 
localized  hsematocele,  which  may  suppurate  later  and  so  produce  one 
of  the  varieties  of  localized  intraperitoneal  abscess ;  (d)  partial  ab- 
sorption, with  the  formation  of  persistent  adhesions ;  (e)  complete 
absorption. 

Peritonitis,  either  diffuse  or  localized,  results  from  the  effusion  of 
blood  into  the  peritoneal  cavity,  quite  apart  irom  infection  at  the 
time  of  the  injury.  Any  effusion  of  blood  into  the  peritoneal  cavity 
which  is  sufficient  in  amount  to  be  capable  of  diagnosis  ought  to  be 
operated  upon.  The  abdomen  must  be  opened,  the  bleeding-point 
secured,  the  blood  and  clot  washed  away  with  sterile  normal  saline 
solution,  and  the  abdomen  closed  without  drainage. 

3.  RETROPERITONEAL    HEMORRHAGE 

In  abdominal  contusions,  especially  when  associated  with  fracture 
of  the  pelvis,  blood  sometimes  escapes  into  the  retroperitoneal  cellular 
tissues  in  such  quantity  as  to  cause  severe  symptoms  of  haemorrhage. 
The  case  is  then  usually  looked  upon  as  one  of  intraperitoneal  haemor- 
rhage, nor  are  there  any  definite  signs  by  which  the  two  conditions 
may  be  distinguished  with  certainty,  even  when  a  more  or  less  localized 
swelling  can  be  felt.  The  diagnosis  has  therefore  to  be  made  by 
exploratory  laparotomy.  When  a  diffuse  retroperitoneal  haemorrh 
is  found  the  wound  should  be  closed  without  drainage,  for  the  blood 


5rH  THE   PERITONEUM 

will  be  absorbed  spontaneously.  Even  a  large  perinephric  swelling 
may  be  so  absorbed,  though  incision  may  be  required  for  secondary 
suppuration  of  the  hematoma. 

DISEASES    OF    THE    PERITONEUM 
I.  INFLAMMATORY 

\.  ACUTE    DIFFUSE   PERITONITIS 

Definition. — A  spreading  inflammation  of  the  peritoneum  which 
is  unlimited  by  adhesions.  To  this  form  the  term  ";  general  peri- 
tonitis pplied,  but  it  is  best  abandoned  as  incorrectly 
implying  that  the  whole  peritoneal  surface  is  involved. 

The  cause  of  such  peritoneal  inflammation  is  in  all  cases  bacterial 
infection.  A  spreading  inflammation  can  be  caused  by  injection  into 
the  peritoneal  cavity  of  sterile  irritating  fluids,  and  to  these  experi- 
mental  forms  the  terms  "  aseptic  "  and  "  chemical  "  peritonitis  were 
formerly  applied.  In  the  same  way  it  was  Jong  thought  that  peri- 
tonitis resulting  from  haemorrhage  into  the  unopened  peritoneal  cavity 
could  cause  a  "  chemical  "  peritonitis,  and  the  same  expression  was 
also  formerly  applied  to  the  peritonitis  which  occurs  in  the  early  stages 
of  intestinal  obstruction.  Bacteriological  examination  of  the  peri- 
toneal surface,  especially  that  covering  the  great  omentum,  as  well 
as  of  the  exudate,  has  thrown  grave  doubt  upon  the  existence  of  a 
non- bacterial  peritonitis. 

According  to  Dudgeon  and  Sargent,  the  Staphylococcus  albus  ap- 
pears to  have  a  distinct  and  definite  part  to  play  in  peritonitis. 
It  makes  its  appearance  early  in  inflammatory  affections  of  the  peri- 
toneum, from  whatever  cause  they  may  arise,  and  can  be  isolated 
from  the  exudate  and  from  the  surface  of  the  bowel  or  omentum.  It 
is  found  in  the  sacs  of  strangulated  hernias  and  in  the  clot  from  an 
intraperitoneal  haemorrhage,  as  well  as  in  the  early  stages  of  inflam- 
mation or  strangulation  of  the  abdominal  viscera.  It  is  probably 
protective  in  function,  determining  the  appearance  of  a  fluid  exudate 
rich  in  phagocytes,  which  do  not  degenerate  in  its  presence,  and 
having  also  to  do  with  the  formation  of  adhesions. 

Just  as  the  resistance  of  the  peritoneum  to  infection  can  be  arti- 
ficially raised  by  the  preliminary  injection  of  various  sterile  fluids, 
notably  nucleic  acid  (von  Mikulicz),  so  the  injection  of  a  culture  of 
this  white  staphylococcus  into  the  peritoneal  cavity  of  an  animal 
is  able  to  protect  it  against  an  otherwise  fatal  dose  of  the  colon 
bacillus  (Dudgeon  and  Sargent). 

Many  different  organisms  are  found  to  cause  peritonitis  in  man, 
the  most  important  by  far  being  the  colon  bacillus.     These  organisms 


ACUTE   DIFFUSE   PERITONITIS  565 

vary  greatly  in  pathogenicity  aa  regards  the  peritoneum.    The  m< 
virulent  is  the  Streptococcus  pyogenes,  and   nexl  to  thai  the  Jina/tus 
ptfocyaneua.     The    colon    bacillus    is    sometimes    extremely    virulent, 
the  differences  in  behaviour  being  due  to  the  particular  strain  | 
and  to  the  patient's  powers  of  resistance.     The  course  of  a  case  of 
peritonitis  depends  upon  many  factors,   the  chief  of  which   are  the 
nature  and  virulence  of  the  infecting  organism,  the  dosage,  the  sudden- 
ness with  which  the  peritoneum  is  invaded,  and  the  power  of  n 
ance  of  the  individual  patient. 

Infection  may  reach  the  peritoneum  by  many  different  channels  : — 

(a)  From  the  exterior    of    the    body,   either  through   an  acci- 

dental or  an  operation  wound  or  along  the  Fallopian  tube. 

(b)  From  some  part  of  the  alimentary  canal. 

(c)  From  disease    of    an   adjacent   organ  other   than   the   ali- 

mentary canal,  such  as  the  gall-bladder  or  the  panci 

(d)  From  an  adjacent   pathological  structure  such   as  a  retro- 

peritoneal abscess  or  an  inflamed  ovarian  c; 

(e)  From  the  blood-stream  (hrernic  infection^. 

The  following  are  the  most  common  forms  of  acute  diffuse  peri- 
tonitis : — 

1.  Colon  Bacillus  Peritoxiii- 

The  great  majority  of  these  cases  originate  from  disease  of  the 
vermiform  appendix.  Perforation  of  that  organ  is  a  frequent  though 
not  a  necessary  starting-point,  for  the  colon  bacillus  can  infect  the 
peritoneum  through  an  acutely  inflamed  or  gangrenous  thougb  im- 
perforated appendix  ;  it  may  spread  from  an  imperfectly  localized  col- 
lection of  pus  around  a  diseased  appendix  ;  or  it  may  result  from  the 
rupture  of  an  appendix  abscess.  Other  causes  of  colon  bacillus  peri- 
tonitis are — penetrating  wounds,  contusions  or  lacerations  of  the 
intestine  ;  intestinal  obstruction  of  any  kind ;  perforation  of  any 
form  of  ulcer,  simple  or  malignant,  of  the  intestine  ;  acute  inflamma- 
tion, gangrene,  or  perforation  of  the  gall-bladder  ;  acute  pancreatitis  ; 
suppuration  and  rupture  of  an  ovarian  cyst  ;  and  inflammation,  gan- 
grene, or  perforation  of  a  Meckel's  diverticulum. 

The  exudate  in  these  cases  is  usually  large  in  amount  ;  that  in  the 
immediate  neighbourhood  of  the  causative  lesion  is  turbid,  and  nun- 
be,  but  is  not  necessarily,  of  an  offensive  odour,  whilst  in  more  remote 
parts  of  the  peritoneal  cavity  it  is  less  turbid  and  odourless.  Cover- 
slip  preparations  from  this  odourless  exudate  usually  show  innumer- 
able leucocytes  and  cocci ;  in  the  exudate  nearer  the  focus  of  infection 
are  seen  cocci,  bacilli,  and  phagocytes,  many  of  which  are  degenerated. 
As  the  peritonitis  spreads,  bacilli  are  found  in  the  exudate  farther 
and  farther  from  the  focus  of  infection ;  the  intestinal  coils  become 


566  THE    PERITONEUM 

progressively  more  reddened,  distended,  and  agglutinated ;  and  flakes 
of  fibrin  are  found  both  floating  in  the  exudate  and  adherent  to  the 
inflamed  peritoneum. 

2.  Acute  Streptococcal  Peritonitis 
The  Streptococcus  pyogenes  may  reach  the  peritoneum  by  direct 
infection  through  accidental  or  even  operation  wounds,  in  puerperal 
sepsis,  and  by  the  blood-stream  in  septicaemia.  Possibly  also  it  may 
in  some  cases  come  from  disease  of  the  alimentary  canal  or  from  an 
infected  ovarian  cyst.  It  also  occurs  as  a  terminal  event  in  some 
cases  of  cutaneous  erysipelas.  It  is  the  most  rapidly  fatal  variety 
of  peritonitis,  in  part  perhaps  because  it  takes  the  form,  when  ori- 
ginating from  the  uterus,  of  a  rapidly  spreading  subserous  cellulitis 
(Murphy) :  in  part  certainly  because  the  intraperitoneal  phagocytosis 
appears  powerless  against  this  form  of  infection. 

There  are  no  distinctive  appearances  by  which  streptococcal  peri- 
tonitis can  be  recognized  at  operation.  As  a  rule,  the  exudate  is  large 
in  amount,  odourless,  and  only  slightly  turbid  ;  intestinal  distension  is 
not  great,  and  agglutination  of  coils  is  absent ;  fibrinous  flakes  are 
scanty  or  absent.  Cover-slip  preparations  show  chains  of  cocci,  together 
with  large  numbers  of  polynuclear  cells,  apparently  in  a  healthy  state, 
but  non-phagocytic  as  regards  the  streptococci.  There  is  little  doubt 
that  the  terminal  event  in  most  of  these  cases  is  a  streptococcal  sep- 
ticaemia. 

3.  Acute  Pneumococcal  Peritonitis 

Whilst  this  form  of  peritonitis  is  more  commonly  secondary  to 
some  pre-existing  pneumococcal  lesion  elsewhere,  it  does  occur  as 
a  primary  affection.  When  primary,  the  pneumococcus  may  reach 
the  peritoneum  through  the  blood,  and  possibly  more  directly  from 
the  bowel ;  it  has  been  known  to  extend  from  a  pyometra  along  the 
Fallopian  tube  (Dudgeon  and  Sargent).  When  secondary,  the  infec- 
tion may  come  from  a  neighbouring  pneumococcal  affection,  such  as 
pleuritis  •  or  the  peritonitis  may  be  septicemic  in  origin,  the  peri- 
toneum being  then  infected  through  the  blood-stream  from  some  focus 
at  a  distance,  such  as  an  otitis  media.  The  pneumococcus  is  said  to 
have  been  found  in  the  exudate  in  a  certain  number  of  cases  of  gastric 
perforation.  The  exudate  in  pneumococcal  peritonitis  is  usually  large 
in  amount  and  greenish  in  colour,  contains  a  quantity  of  fibrinous 
flakes,  and  is  quite  odourless.  There  are,  however,  no  definite  clinical 
signs  by  which  it  can  be  recognized,  the  only  certain  method  being 
the  bacteriological  examination  of  the  exudate.  It  may  be  suspected 
at  operation  if  the  exudate  shows  the  above-mentioned  characteristics, 
whilst  no  definite  lesion  can  be  found  to  account  for  the  peritonitis, 
especially  when  the  patient  is  a  child. 


ACUTE   DIFFUSE    PERITONITIS  567 

4.  Acute  Gonococh  ll  PEBrroNms 
Acute  diffused  gonococcal  peritonitis  is  occasionally  met  with 
The  organism  reaohes  the  peritoneum  either  through  the  open  mouth 
of  a  Fallopian  tube,  01  by  leakage  Erom  01  rupture,  of  ;i  pyosalpinz.  II 
does  not  readily  affect  the  peritoneum,  and  when  it  docs  so  is  apl  to 
produce  a  form  of  peritonitis  which,  although  sometimes  oi  Budden 
or  acute  onset,  usually  runs  a  mild  and  favourable  course,  and  is  un- 
accompanied by  intestinal  distension.  The  exudate  is  scanty,  usually 
clear  or  only  very  slightly  turbid,  and  distinctly  viscid.  Cover-slip 
preparations  occasionally  show  intracellular  diplococci. 

5.  Other  Forms  of  Acute  Peritonitis 
The  organisms  more  rarely  found  in  acute  diffuse  peritonitis  are 
B.  pyocyaneus,  Staphylococcus  pyogenes  aureus  and  other  forms  of 
pyogenetic  staphylococci,  and  B.  typhosus.  The  last-named  may  reach 
the  peritoneum  from  a  suppurating  mesenteric  gland  (Korte),  and  per- 
haps from  the  intestine  without  perforation.  The  peritonitis  result- 
ing from  perforation  of  a  typhoid  ulcer  is  a  mixed  infection,  the  colon 
bacillus  predominating. 

Veillon  and  Zuber  have  described  certain  anaerobic  organisms 
as  occurring  in  peritonitis,  as  also  have  Tavcl  and  Lanz.  Dudgeon 
and  Sargent  only  once  found  an  anaerobic  organism,  namely,  the 
B.  aerogenes  capsulatus,  and  consider  that  anaerobes  do  not  play  an 
important  part  in  peritonitis. 

Symptoms  of  acute  diffuse  peritonitis. — The  clinical 
history  and  symptoms  of  the  disease  or  injury  which  has  allowed 
the  infection  to  reach  the  peritoneum  are  dealt  with  elsewhere.  In 
the  later  stages  the  peritoneal  symptoms  so  overshadow  those  of  the 
original  lesion  that  in  the  majority  of  cases  its  nature  oan  only  be 
ascertained  by  the  operation  which  the  peritonitis  makes  imperative. 

The  onset  is  often  sudden,  or  at  least  rapid,  and  is  accompanied  by 
abdominal  pain.  At  first  diffuse,  the  pain  may,  after  a  short  time, 
become  sufficiently  localized  to  be  of  diagnostic  value  ;  later,  again, 
it  becomes  generalized  over  the  whole  abdomen. 

Vomiting  is  a  symptom  which  is  rarely  absent.  It  is  persistent. 
and  accompanied  by  nausea  and  straining,  differing  in  these  respects 
from  the  vomiting  of  intestinal  obstruction.  The  vomitus  is  commonly 
green  in  colour,  and  does  not  become  feeculent.  The  occurrence  of 
"black  vomit"  is  one  of  the  most  serious  symptoms  in  a  bad  case 
of  peritonitis.  Constipation  is  present  from  the  outset,  and  becomes 
more  marked  with  the  progressive  paralysis  of  the  intestine.  The 
tongue,  at  first  furred  and  moist,  soon  becomes  dry  and  brown. 

The  temperature  affords  little  information.     At  the  onset  it  may 


68  THE   PERITONEUM 

be  subnormal  from  the  shock  of  a  perforation  or  strangulation  ;  on  the 
other  hand,  it  is  often  raised  at  first,  and  sometimes  the  onset  is 
marked  by  a  rigor.  As  the  peritonitis  spreads,  the  temperature  falls 
to  and  below  the  normal. 

The  pulse-rate  is  of  much  greater  importance.  Rapid  at  the  onset, 
it  may  become  slowed  as  the  initial  shock  passes  off,  only  to  rise  again 
steadily  and  progressively  with  the  spread  of  the  peritonitis.  At  the 
same  time  it  becomes  feeble  and  "  thready."  One  of  the  most  reliable 
indications  of  a  spreading  peritonitis  is  the  coexistence  of  a  rising 
pulse-rate  and  a  falling  temperature. 

The  fades  is  important.  The  patient  quickly  assumes  a  charac- 
teristic appearance,  the  face  being  pale,  drawn,  and  anxious-looking, 
whilst  dark  rings  appear  round  the  sunken  eyes.  The  mental  condition 
is  clear,  and  in  fatal  cases  the  patient  is  only  too  conscious  of  his  con- 
dition until  the  end. 

Examination  of  the  abdomen  by  inspection,  palpation,  and  per- 
cussion should  be  thoroughly  and  systematically  carried  out.  The 
abdomen  is  rigid  and  often  extremely  tender,  and  the  abdominal  respira- 
tory movements  are  diminished.  In  the  early  stages  this  rigidity  and  the 
diminution  of  respiratory  movements  may  be  so  localized  as  to  afford 
valuable  evidence  as  to  the  situation  of  the  starting-point  of  the  peri- 
tonitis. Later,  the  whole  abdomen  becomes  rigid  and  motionless.  As 
the  disease  progresses,  the  abdomen,  which  may  at  first  have  been 
flat,  or  even  sunken,  becomes  progressively  distended  from  intestinal 
paralysis,  and  the  distension  may  become  so  great  as  seriously  to 
interfere  with  respiration.  The  presence  of  free  fluid  may  sometimes 
be  ascertained  by  the  somewhat  fallacious  sign  of  shifting  dullness  in 
the  flanks. 

In  peritonitis  from  intestinal  perforation  there  may,  in  addition, 
be  evidence  of  free  gas  in  the  peritoneal  cavity.  This  is  shown  by 
diminution  or  absence  of  the  normal  area  of  liver  dullness,  especially 
when  it  occurs  in  a  flat  abdomen.  Intestinal  distension  may  simulate 
this  sign  very  closely. 

In  old  persons  many  of  the  above-mentioned  symptoms  may  be 
absent.  The  abdomen  is  sometimes  observed  to  be  both  soft  and 
mobile,  even  in  the  presence  of  an  acute  spreading  peritonitis.  Simi- 
larly, both  rigidity  and  immobility  are  often  absent  in  postoperative 
peritonitis. 

Nearly  all  these  symptoms  and  signs  may  be  modified  or  abolished 
by  the  administration  of  opium.  A  patient  under  its  influence  may 
look  comparatively  well,  vomiting  may  be  absent,  the  pulse  may  be 
only  slightly  accelerated,  the  abdomen  may  be  soft  and  moving  with 
respiration,  and  examination  may  not  be  resented. 

Diagnosis. — Acute  peritonitis  has  to  be  diagnosed  from  intes- 


ACUTE    DIFFUSE    PERITONITIS 

final  obstruction,  the  clinical  features  of  which  are  detailed  ;it    p.  465. 
In  addition  to  establishing  the  fool  thai  diffuse  peritonitis  is  p* 
an   attempt  must   be   made    to  ascertain    the   starting-point   <>f  the 
peritoneal  infection. 

Treatment. — The  presence  of  acute  diffuse  peritonitis  urgently 
demands  operation,  every  hour  that  passes  between  onsel  and  opera- 
tion rendering  the  prognosis  increasingly  grave.  Whilst  preparations 
are  being  made  for  the  operation  the  patient  should  not  l>e.  allowed  to 
lie  Hat  upon  the  back,  but  should  be  propped  up  in  bed  almost  in  a 
sitting  posture  (Fowler's  position,  Fig.  466,  p.  639)  ;  if  he  has  to  be 
transferred  to  hospital  a  similar  posture  should  be  adopted  on  the 
journey.  Opium  should  not  be  given,  not  only  on  account  of  its 
tendency  to  diminish  intestinal  movements  and  add  to  the  paralytic 
distension  of  the  bowel,  but  also  because  it  inhibits  intraperitoneal 
phagocytosis  (Dudgeon  and  Ross). 

The  operation  consists  of  two  essential  parts,  namely,  the  removal 
of  the  focus  of  infection,  and  the  treatment  of  the  peritoneum. 

1.  Removal  of  the  focus  of  infection. — If  before  operation 
a  decision  has  been  arrived  at  as  to  the  source  of  the  infection,  the 
abdomen  should  be  opened  as  nearly  as  possible  over  that  point. 
When  the  source  of  infection  is  uncertain,  the  most  generally  useful 
incision  is  that  which  separates  the  fibres  of  the  right  rectus  muscle  just 
below  the  umbilicus,  as  this  allows  the  appendix  region  to  be  explored 
at  once,  and  also  gives  easy  access  to  the  pelvic  organs.  The  methods 
of  dealing  with  any  particular  lesion  that  may  be  found  are  discussed 
elsewhere  under  various  headings,  such  as  Removal  of  the  Appendix 
(p.  554),  Suture  of  a  Ruptured  Gastric  Ulcer  (p.  357),  Removal  of 
Suppurating  Tubes  (p.  1054),  and  so  on. 

2.  Method  of  dealing  with  the  peritoneum.— The  error  of 
attempting  to  cleanse  the  peritoneum  by  heroic  methods  of  lavage  has 
been  amply  demonstrated  both  by  clinical  results  and  on  pathological 
grounds.  No  amount  of  washing  will  rid  the  peritoneum  of  infective 
material,  while  the  disturbance  occasioned  by  such  manipulations  tends 
to  spread  infection  beyond  the  area  already  involved,  destroys  the 
phagocytes  which  alone  can  effectively  deal  with  the  micro-organisms., 
injures  the  delicate  peritoneal  endothelium,  so  rendering  hsemic  absorp- 
tion more  easy,  and  increases  the  shock  of  the  operation.  Once  the 
focus  of  infection  has  been  removed,  the  less  that  is  done  to  the  peri- 
toneum the  better,  and  all  manipulations  ought  to  be  of  the  gentlest 
possible  character.  Any  collection  of  pus  which  may  lie  in  the  imme- 
diate neighbourhood  of  the  starting-point  of  the  infection,  and  any 
pools  of  fluid  that  may  have  collected  in  the  pelvis  or  lumbar  regions, 
may  be  gently  mopped  up  with  dry  sterilized  gauze.  On  no  account 
should  flakes  of  "  lymph  "  be  peeled  off  the  bowel. 


570  THE    PERITONEUM 

This  done,. a  drainage  tube  of  large  calibre  may  be  inserted  down 
to  the  site  of  the  lesion,  either  through  the  original  wound  or  through 
some  new  opening — in  the  loin,  for  example — which  may  be  considered 
more  suitable  for  drainage.  Gauze  strips  are  sometimes  used  for  this 
purpose,  but  they  do  not  act  well  as  drains,  and  their  removal  is  attended 
by  considerable  pain.  The  "  cigarette  "  drain,  which  consists  of  a 
piece  of  "  green  protective  "  or  rubber  tissue  wrapped  round  a  loosely 
arranged  roll  of  gauze  in  the  form  of  a  cigarette,  is  sometimes  used, 
but  is  not  so  effective  as  a  tube.  A  good  plan  is  to  pass  a  narrow  strip 
of  gauze  down  the  rubber  tube  ;  this  can  easily  be  changed,  and  serves 
the  purpose  of  preventing  the  tube  from  becoming  blocked  by  coagu- 
lated blood  and  pus. 

Sometimes  lavage  of  the  peritoneal  cavity  is  advisable,  as  in  those 
cases  of  ruptured  gastric  or  duodenal  ulcer  in  which  the  peritoneal 
cavity  is  flooded  with  acrid  gastric  contents  and  solid  particles  of  food, 
and  in  certain  cases  of  intraperitoneal  haemorrhage  when  it  is  desirable 
to  wash  away  large  quantities  of  blood  and  clot.  In  such  instances 
the  interference  with  intraperitoneal  phagocytosis  is  of  less  moment 
than  the  desirability  of  ridding  the  peritoneum  of  foreign  matter. 
Drainage  is  not  always  necessary.  It  is  not  required  in  intraperitoneal 
haemorrhage,  in  peritonitis  from  an  inflamed  cyst,  in  gonorrhceal  peri- 
tonitis, or  in  the  great  majority  of  cases  of  ruptured  gastric  ulcer. 
These  are  all  instances  of  peritonitis  in  which  the  infection  is  of  a  mild 
type.  In  colon  bacillus  infections,  on  the  other  hand,  represented  by 
the  vast  majority  of  cases  of  peritonitis  of  intestinal  origin,  it  is  usually 
advisable  to  leave  a  drain  down  to  the  original  site  of  the  infection. 

After-treatment. — Posture  is  important.  The  Fowler  position 
is  now  widely  adopted,  the  patient  being  propped  up  almost  in  a 
sitting  position,  with  the  object  of  preventing  the  gravitation  of  fluid 
upwrards  towards  the  diaphragm  (Fig.  466,  p.  639).  If  this  position 
be  used,  careful  watch  should  be  kept  for  any  collection  of  pus  in  the 
pelvis. 

When  the  patient  has  been  put  back  into  bed,  every  effort  must  be 
directed  towards  combating  shock.  The  various  means  of  dealing  with 
this  condition  are  explained  in  Vol.  I.,  p.  330. 

It  is  of  the  utmost  importance  to  get  the  bowels  opened  freely  as 
soon  as  possible  ;  a  dose  of  calomel  may  be  followed  by  repeated  doses 
of  magnesium  sulphate  until  a  free  action  is  obtained,  and  enemata 
containing  turpentine  are  often  useful.  Subcutaneous  injection  of 
pituitary  extract  (TT]xv  of  a  20  per  cent,  solution)  appears  to  be  useful 
in  stimulating  peristaltic  action.  In  this  connexion  it  should  be  re- 
membered that  the  administration  of  opium  is  to  be  avoided. 

The  continuous  administration  of  saline  solution  per  rectum  by 
Murphy's  method  has  many  advocates,  and  good  results  are  obtained 


ACUTE   DIFFUSE    PERITONITIS  571 

by  its  use.  A  pliable  t ul><;  of  soft  metal,  provided  with  many  open* 
ings,  ia  inserted  in  the  rectum,  and  connected  with  a  reservoir  con- 
taining normal  saline  solution  maintained  al  a  temperature  oi 
1<>.~>  to  110  F.  The  reservoir  is  raised  from  one  to  two  f''i't  above 
the  level  of  the  buttocks,  and  the  fluid  allowed  to  run  slowly  in.  B 
this  means  some  twelve  or  more  pints  <»f  fluid  can  be  absorbed  in  .1 
day.  Care  must  be  taken  to  keep  the  quantity  within  reasonable 
limits,  lest  the  lungs  become  waterlogged. 

If  drainage-tubes  have  been  used,  they  should  not  be  allowed  to 
remain  in  place  for  more  than  three  or  four  days,  liv  thai  time  they 
will  have  done  all  that  can  be  done  by  drainage,  and  longer  retention 
may  be  followed  by  a  troublesome  sinus  and  an  unnecessary  weakening 
of  the  abdominal  wall. 

Vomiting  may  be  controlled  by  small  repeated  doses  of  tincture  of 
iodine  or  of  cocaine  ;  sometimes  gastric  lavage  may  be  advantage- 
ously employed. 

The  use,  in  cases  of  B.  coli  peritonitis,  of  a  multivalent  anti-coli 
serum  has  yielded  promising  results,  and  may  be  given  a  trial. 

Complications  of  acute  diffuse  peritonitis.— -Most  of 
the  fatal  cases  terminate  by  septic  intoxication,  and  many  from  a 
general  septicaemia.  When,  with  the  removal  of  the  focus  of  infec- 
tion, and  the  placing  of  the  peritoneum  under  the  best  conditions 
for  dealing  with  the  remaining  infection,  death  from  these  causes 
has  been  averted,  the  chief  complications  to  be  looked  for  are  the 
following  : — 

1.  Intestinal  obstruction. — Paralytic  distension  is  very  common, 
and,  unless  peristaltic  action  is  quickly  restored,  death  from  septic 
absorption  will  soon  occur.  But,  apart  from  this  paralytic  form  of 
obstruction,  mechanical  obstruction  may  occur  from  adhesions  and 
kinking  of  the  bowel.  This  is  shown  by  inability  to  get  the  bowels 
open  in  spite  of  the  presence  of  peristalsis,  by  increasing  distension, 
and  by  renewed  vomiting  which  sooner  or  later  becomes  faeculent  in 
type.  A  further  operation  (enterostomy  or  enterolysis)  may  possibly 
succeed,  but  the  outlook  in  such  cases  is  extremely  grave. 

2.  Cellulitis  and  gangrene  of  the  abdominal  wall  around  the 
wound  are  occasional,  but  very  uncommon,  complications. 

3.  Residual  abscesses. — After  the  subsidence  of  a  diffuse  peri- 
tonitis a  localized  collection  of  pus  may  appear  anywhere  within  the 
peritoneal  cavity.  The  commonest  variety  is  the  subphrenic  abscess 
{see  p.  572) ;  whilst  after  the  use  of  the  Fowler  position,  without  effi- 
cient drainage  of  the  pelvis,  a  pelvic  accumulation  of  pus  may  occur. 

4.  Pneumonia  and  empyema. — These  complications  sometimes 
occur  within  the  first  week  or  fortnight  after  the  operation  for  diffuse 
peritonitis. 


572  THE   PERITONEUM 

B.  LOCALIZED   INTRAPERITONEAL   SUPPURATION 

Localized  collections  of  pus  within  the  peritoneal  cavity  may 
result  from  a  large  number  of  different  causes.  The  commonest 
variety  is  the  localized  appendix  abscess  ;  others  are  due  to  disease 
of  the  female  pelvic  organs,  to  slow  leakage  from  a  gastric  or  duo- 
denal ulcer,,  to  inflammatory  processes  around  a  cancerous  growth  of 
the  intestine.,  and  to  disease  of  the  gall-bladder,  bile-ducts,  or  pancreas  ; 
others  are  those  already  described  as  "  residual "  abscesses,  which 
may  occur  in  any  part  of  the  peritoneal  cavity  after  the  subsidence 
of  a  diffuse  peritonitis  ;  whilst  others,  again,  are  due  to  the  chronic 
forms  of  tuberculous  or  pneumococcal  peritonitis,  to  be  described 
later.  Suppurative  epiploitis  constitutes  still  another  variety  of 
localized  aba 

The  situations  in  which  such  abscesses  tend  to  form  have  already 
been  indicated  in  describing  the  anatomy  of  the  peritoneal  compart- 
ments ;  but  it  not  infrequently  happens  that  adhesions  alter  the 
course  of  a  tracking  collection  of  pus,  and  that  perforation  of  the  peri- 
toneum forming  the  abscess  wall  may  allow  the  pus  to  escape  into  the 
retroperitoneal  tissue,  so  as  to  form  an  abscess  in  situations  uninflu- 
enced by  the  anatomical  disposition  of  the  peritoneum. 

In  addition  to  the  symptoms  of  the  disease  from  which  the  abscess 
originated,  those  presented  by  a  localized  intraperitoneal  abscess  are 
abdominal  pain  and  tenderness,  together  with  toxaemia.  The  course 
may  be  very  slow  and  the  diagnosis  difficult.  In  the  simpler  cases  a 
firm  and  definite  intra-abdominal  tumour  may  be  felt ;  others  have  to 
be  diagnosed  by  the  general  symptoms,  added  to  those  of  pressure 
effects  upon  neighbouring  structures  such  as  the  base  of  the  lung. 

One  variety  of  localized  abscess  must  be  considered  separately, 
namely,  subphrenic  or  subdiaphragmatic  abscess. 

Subphrenic  Abscess 

Definition. — A  collection  of  pus  beneath  the  diaphragm,  lying 
on  the  right  side  between  the  liver  and  diaphragm,  and  on  the  left 
between  the  diaphragm  and  the  stomach  and  spleen.  The  term  is  often 
used  to  include  abscesses  situated  in  the  right  kidney  well,  when  the  pus 
is  really  subhepatic  rather  than  subphrenic. 

Causation. — The  possible  causes  of  subphrenic  abscess  are  very 
numerous,  for  almost  any  intra-abdominal  lesion  may  give  rise  to  it, 
whilst  occasionally  the  spread  is  in  the  reverse  direction,  suppuration 
above  the  diaphragm  giving  rise  to  infection  below.  The  most  common 
causes  are  perforation  of  an  ulcer  of  the  stomach  or  duodenum, 
suppurative  conditions  of  the  liver  and  its  ducts,  and  appendicitis. 
Renal,  pancreatic,  and  traumatic  suppurations  are  occasional  catises. 


SUBPHRENIC   ABSCESS  573 

Pathology. — The  bacteriology  of  subphrenic  abscess  is  as  varied 
as  that  of  peritonitis.  Pus  spreading  from  the  primary  focus  may 
find  itself  at  once  in  the  subphrenic  region,  or  it  may  reach  this 
region  from  a  distance,  traversing  intraperitoneally  the  anatomical 
routes  already  considered,  or  paths  determined  by  adhesions,  or  spread- 
in^  in  the  retroperitoneal  tissue  of  the  posterior  abdominal  wall.    Per- 

I  ion  of  the  diaphragm  is  said  to  be  more  likely  to  occur  in  the  last- 
named  class  of  case.  In  a  certain  number  of  cases  (about  15  per  cent.) 
the  cavity  of  a  subphrenic  abscess  contains  gas,  which  may  be  present 
either  as  the  result  of  bacterial  activity  within  the  abscess,  or  may 
have  gained  admission  by  direct  continuity  from  the  alimentary  canal, 
or  even  from  the  air-passages. 

Symptoms  and  diagnosis. — The  onset  may  be  very  acute 
and  present  most  of  the  features  of  an  abdominal  ''  catastrophe  "  ; 
it  may  be  subacute,  with  pain  in  the  upper  part  of  the  abdomen,  fever, 
and  possibly  a  rigor,  and  pain  in  the  shoulder  is  common.  Pain  and 
tenderness  over  the  lower  ribs,  and  limitation  of  the  respiratory  move- 
ments, together  with  cough,  slight  expectoration,  and  irregular  fever, 
following  upon  a  history  of  gastric  ulcer,  an  operation  for  suppurative 
appendicitis,  or  other  recognizable  cause  of  subphrenic  suppuration, 
would  make  up  a  clinical  picture  of  such  a  case.  The  onset  may,  on 
the  other  hand,  be  so  slow  and  insidious,  and  present  so  few  localizing 
symptoms  and  physical  signs,  as  to  make  the  diagnosis  a  matter  of 
the  greatest  difficulty. 

As  the  symptoms  and  causes  vary  within  such  wide  limits,  so  also 
do  the  physical  signs.  Broadly  speaking,  the  physical  signs  are  those 
of  a  limited  collection  of  fluid  at  the  base  of  the  lung.  In  a  well- 
marked  case  there  may  be  an  area  of  dullness  sharply  marked  off  from 
the  resonance  of  the  lung  above,  together  with  loss  of  breath  sounds 
and  diminution  or  loss  of  vocal  fremitus  and  resonance.  When  the 
abscess  contains  gas  there  may  be  on  percussion  a  characteristic  series 
of  changes  from  the  dull  area  below,  through  a  tympanitic  area,  up  to 
the  normal  pulmonary  resonance.  Alteration  of  the  position  of  the 
patient  may  cause  alteration  of  the  position  of  the  resonant  area  as 
the  gas  and  pus  adjust  themselves  to  the  new  position. 

The  lower  lobe  of  the  lung  may  be  so  compressed  as  to  present  a 
zone  of  tubular  breathing  and  impaired  resonance  above  the  level  of 
absolute  dullness.  If  the  collection  is  a  large  one,  the  liver  may  be 
pushed  downwards  so  as  to  be  easily  palpable  below  the  costal  margin  ; 
the  heart  may  be  displaced  upwards.  A  screen  examination  with  the 
X-rays  sometimes  proves  most  valuable  by  indicating  the  level  and 
degree  of  mobility  of  the  diaphragm. 

The  diagnosis  is  often  complicated  by  the  presence  of  clear  or  puru- 
lent fluid  in  the  pleural  cavity  above  the  subphrenic  collection.     The 


574 


THE   PERITONEUM 


DIAPHRAGM 


diaphragm  is  sometimes  perforated,  so  that  the  subphrenic  and  pleural 
collections  of  pus  communicate  with  one  another. 

Exploratory  puncture  with  an  aspirating  needle  cannot  be  too 
severely  condemned.  The  procedure  is  far  more  dangerous  than  an 
exploratory  operation,  and  a  negative  result  is  valueless. 

Treatment. — The  abscess  must  be  opened  as  soon  as  its  presence 
has  been  determined.  The  actual  site  of  the  opening  will  be  indicated 
by  the  situation  of  the  pus,  as  shown  by  percussion,  position  of  ten- 
derness, palpation,  and 
X  -  ray  examination. 
Occasionally  such  an 
abscess,  if  coming  for- 
ward, can  be  reached 
by  an  incision  through 
the  anterior  abdominal 
wall  below  the  costal 
margin,  and  posterior- 
ly situated  collections 
have  been  reached  by 
an  incision  below  the 
costal  margin  behind, 
though  in  doing  this 
there  is  risk  of  acci- 
dentally wounding  and 
infecting  the  pleura. 

The  method  adapt- 
ed to  the  majority  of 
cases  is  that  of  de- 
liberately traversing 
the  pleural  cavity  and 
diaphragm.  The  struc- 
tures which  have  to  be  traversed  are  shown  diagrammatically  in  Fig. 
441.  If  the  patient  is  very  ill  the  operation  can  be  done  under  local 
anaesthesia. 

The  operation,  briefly,  consists  in  resecting  portions  of  two  or  three 
ribs  over  the  site  of  the  abscess,  opening  the  pleural  cavity,  suturing 
the  diaphragm  to  the  costal  pleura,  so  as  to  shut  off  the  pleural 
cavity,  incising  the  diaphragm,  and  inserting  a  drainage-tube.  Some 
surgeons  prefer  to  perform  this  operation  in  two  stages,  the  first  stage 
being  directed  to  shutting  off  the  pleural  cavity,  and  the  second  to 
opening  the  abscess.  The  danger  of  infecting  the  pleura  in  the  one- 
stage  operation  has  been  exaggerated,  and  there  is  little  to  be  said  in 
favour  of  the  two-stage  procedure.  In  some  cases  an  empyema  is 
present  in  addition  to  the  subphrenic  abscess  ;  when  this  is  so,  doubt 


Fig.  441.- — Diagram  showing  structures  tra- 
versed in  opening  a  subphrenic  abscess. 


PERITONITIS  575 

may  arise  as  to  whether  there  is  also  pus  beneath  the  diaphragm  ;  the 

operator  would  then  be  content  to  drain  the  empyema  and  to  await 
events. 

Prognosis.  Hair  instances  have  occurred  of  spontaneous  ter- 
mination either  by  absorption  or  evacuation  of  the  pus.  With  such 
reported  exceptions  the  condition,  if  unrelieved  by  operation,  ter- 
minates fatally,  sometimes  after  a  very  prolonged  period  of  illness. 
Extension  or  rupture  of  the  abscess  may  take  place  into  the  pleural 
cavity,  the  pericardium,  the  bronchi,  or  t he  general  peritoneal  cavity, 
and  the  patient  dies  from  these  complications  or  from  prolonged  sup- 
puration and  septic  poisoning.  Early  operation,  on 'the  other  hand, 
offers  a  fairly  good  prospect  of  recovery,  and  the  mortality  of  such 
cases  may  be  placed  at  between  30  and  40  per  cent. 

There  is  a  tendency  to  the  formation  of  fresh  loculi  of  pus  even  after 
the  primary  collection  has  been  evacuated,  and  in  the  event  of  the 
temperature  not  subsiding,  fresh  efforts  should  be  made  to  find  such 
collections. 

C.  CHRONIC   FORMS    OF   PERITONITIS 

1.  Chronic  Septic  Peritonitis 

Localized  intraperitoneal  abscess  has  already  been  considered  (p. 
572).  A  form  of  peritonitis  intermediate  between  these  cases  and  those 
of  acute  diffuse  peritonitis  can  sometimes  be  recognized,  coming  on 
after  the  subsidence  of  an  acute  diffuse  peritonitis,  and  characterized 
clinically  by  irregular  fever,  diarrhoea,  and  progressive  emaciation  ; 
from  time  to  time  collections  of  pus  large  enough  to  be  recognized 
and  opened  make  their  appearance.  Post  mortem,  there  is  a  general 
matting  together  of  the  abdominal  contents,  in  the  midst  of  which 
are  found  loculi  of  pus  of  various  sizes,  which  often  communicate 
with  one  another  by  narrow  fistulous  tracks,  and  an  extreme  thicken- 
ing of  the  peritoneum  from  fibrinous  deposit  more  or  less  organized 
(Plate  98,  Fig.  2).  In  such  cases  the  pyogenetic  staphylococci,  the 
colon  bacillus,  and  the  Bacillus  pyocyaneus  have  been  found. 

2.  Chronic  Gonococcal  Peritonitis 

The  gonococcus,  whilst  only  an  occasional  cause  of  acute  diffuse 
peritonitis,  frequently  produces  a  chronic  form  of  peritonitis  which, 
from  its  almost  invariable  starting-point  in  the  Fallopian  tubes,  chiefly 
concerns  the  pelvic  peritoneum.  The  resulting  peritonitis  is  slow 
and  insidious  in  its  course,  produces  few  or  no  symptoms  apart  from 
those  of  the  initial  lesions,  and  leads  to  the  formation  of  adhesions 
which  may  mat  together  the  pelvic  viscera  and  may  cause  intestinal 
obstruction. 


576  THE    PERITONEUM 

3.  Chronic  Pneumococcal  Peritonitis 
Like  the  gonococcus,  the  pneumococcus  may  produce  either  an 
acute  and  diffuse,  or  a  localized  and  chronic  peritonitis.  The  chronic 
form  closely  resembles  tuberculous  peritonitis,  both  in  its  clinical 
course  and  in  its  local  effects  upon  the  peritoneum,  and  the  two  diseases 
can  scarcely  be  distinguished  except  by  a  bacteriological  examination. 
The  diagnosis  may  have  to  rest  upon  the  discovery  of  some  recognizable 
pneumococcal  or  tuberculous  lesion  elsewhere. 

D.  TUBERCULOUS   PERITONITIS 

The  forms  in*  which  peritoneal  tuberculosis  occurs  are — ■ 

1.  The  miliary  form,  in  which  the  peritoneum  is  affected  merely  as 
part  of  a  general  miliary  tuberculosis.    This  form  is  of  no  surgical  interest. 

2.  A  form  in  which  the  peritoneal  affection  is  either  primary  or — 
being  secondary,  as  is  more  common — constitutes  the  predominant 
feature  of  the  case. 

The  infection  reaches  the  peritoneum  either  through  the  blood- 
stream from  some  focus  at  a  distance,  such  as  the  lung ;  or  more 
directly  from  a  neighbouring  focus,  such  as  intestinal  ulceration,  a 
tuberculous  mesenteric  gland,  or  a  tuberculous  Fallopian  tube. 

Clinically  the  disease  appears  in  two  chief  varieties,  which,  how- 
ever, merge  into  one  another,  namely,  the  ascitic  and  the  adhesive. 
In  the  former  the  exudation  is  the  chief  clinical  feature,  the  peritoneum 
being  studded  with  tuberculous  nodules  of  varying  sizes  ;  in  the  latter 
the  intestines  and  omentum  are  matted  together  in  an  inextricable 
mass,  in  the  midst  of  which  are  collections  of  broken-down  caseous 
material  of  various  sizes.  Such  collections  are  liable  to  become  second- 
arily infected  with  pyogenetic  organisms  from  the  intestine,  and  to 
form  acute  or  subacute  intraperitoneal  abscesses.  With  one  or  more 
of  these  abscesses  the  intestine  may  communicate  by  fistulous  tracks, 
and  such  abscesses  becoming  adherent  to  and  perforating  the  abdo- 
minal wall,  or  being  opened  surgically,  may  produce  intractable  faecal 
fistulse.  The  umbilicus  is  a  common  site  for  such  a  fistula  to  arise 
spontaneously. 

Symptoms. — Tuberculous  peritonitis  is  chiefly  a  disease  of  child- 
hood and  young  adult  life,  though  it  is  sometimes  met  with  in  older 
patients.  It  runs  a  slow  course,  and  is  characterized  principally  by 
progressive  emaciation  which  may  be  accompanied  by  irregular  slight 
fever.  Attacks  of  pain  and  vomiting  occur  at  intervals,  but,  unless 
proceeding  from  a  definite  intestinal  obstruction,  they  are  not  severe. 
In  some  cases  diarrhoea  is  a  marked  feature.  Secondary  infection  of 
intraperitoneal  abscesses  may  cause  more  acute  symptoms  and  may 
necessitate  incision. 

Examination  of  the  abdomen  reveals,  in  the  ascitic  variety,  the 


TUHKRCTLOUS    PERITONITIS  577 

physical  signs  of  bee  tlui<l  within  the  abdomen.  The  distension  n 
become  very  marked,  so  that  the  belly  wall  appears  tense  and  shiny, 
with  dilated  veins  upon  its  surface  and  a  prominenl  umbilicus  ;  respira- 
tory and  cardiac  embarrassment  may  thus  be  caused.  The  fluid  may 
find  its  way  into  a  patent  funicular  process,  and.  unless  there  is  some- 
thing to  call  attention  to  the  abdomen,  such  a  case  may  easily  be 
mistaken  for  one  of  simple  congenital  hydrocele. 

In  the  adhesive  variety  it  is  often  possible  to  feel  nodules  or  irregu- 
lar masses  of  various  sizes  scattered  throughout  the  abdomen. 

Diagnosis. — A  characteristic  case  presents  little  difficulty,  though 
it  may  be  closely  mimicked  by  the  ehronic  form  of  pneumococcal 
peritonitis. 

On  the  other  hand,  tuberculous  peritonitis  may  assume  forms  in 
which  the  diagnosis  is  a  matter  of  the  greatest  difficulty  and  may  have 
to  be  decided  by  exploratory  laparotomy.  Thus,  malignant  disease  of 
the  peritoneum,  especially  when  accompanied  by  the  presence  of  palpable 
masses  and  of  ascites,  may  be  quite  indistinguishable  from  tuberculous 
peritonitis  except  by  surgical  exploration.  An  encysted  collection  of 
fluid  in  tuberculous  peritonitis  may  readily  be  mistaken  for  an  ovarian 
cyst,  or  for  a  local  intraperitoneal  abscess  due  to  some  other  cause. 

In  a  case  with  acute  onset,  accompanied  by  fever  and  diarrhoea, 
the  diagnosis  from  enteric  fever  may  be  most  difficult.  The  greater 
irregularity  of  the  fever,  especially  when  observed  over  a  period  of 
several  weeks,  together  with  the  absence  of  rash,  of  splenic  enlarge- 
ment, and  of  bronchitis,  and  the  negative  Widal  reaction,  would  serva 
to  distinguish  tuberculous  peritonitis.  Some  assistance  may  be  gained 
from  Calmette's  or  von  Pirquet's  tuberculin  test. 

Treatment. — Treatment  by  medical  means,  hygienic  and  dietetic, 
such  as  is  suitable  for  tuberculosis  in  general,  may  be  followed  by 
good  results.  Tuberculin  may  also  be  tried  in  suitable  cases.  The 
tapping  of  a  large  ascitic  collection  may  afford  relief,  but  does  not 
give  such  good  results  as  laparotomy,  and  is  by  no  means  free  from 
the  risk  of  puncturing  adherent  intestine. 

Treatment  by  surgical  means  is  often  indicated,  and  is  frequently 
followed  by  results  sufficiently  good  to  be  justly  denominated  cures. 
It  is  chiefly  in  the  ascitic  form  that  operation  holds  out  such  favour- 
able prospects.  The  operation  is  of  the  simplest  character,  and  con- 
sists in  making  a  small  incision,  some  two  or  three  inches  long,  through 
one  or  other  rectus  abdominis  muscle  in  the  direction  of  its  fibres.  The 
fluid  is  allowed  to  escape,  and  the  little  wound  is  closed  and  dressed 
with  collodion.  Xo  advantage  appears  to  attach  to  the  flushing  or 
mopping-out  of  the  peritoneal  cavity,  still  less  to  the  introduction  of 
antiseptics.  Occasionally  a  definite  tuberculous  focus  of  origin  can 
be  removed  at  the  same  time,  such  as  a  Fallopian  tube  or  a  lymph 
2/ 


578  THE    PERITONEUM 

gland.  The  coexistence  of  phthisis  or  other  tuberculous  focus,  unless 
of  an  advanced  character,  is  no  contra-indication  to  operation. 

Other  operative  measures  are  called  for  in  certain  cases,  as  for  the 
relief  of  intestinal  obstruction,  or  the  opening  of  localized  infected 
abscesses.  When  fistulse  are  present,  no  surgical  procedure  is  likely  to 
be  of  any  benefit. 

Prognosis. — The  immediate  result  of  operation  in  the  ascitic 
form,  and  in  dealing  with  encysted  collections  of  exudate,  is  strikingly 
beneficial,  whilst  the  operative  risk  is  very  small.  Rorsch's  series  of 
collected  cases  showed  an  operation  mortality  of  5'6  per  cent.,  70  per 
cent,  of  immediate  cures,  and  14*8  per  cent,  of  cures  of  two  or  more 
years'  duration. 

II.    TUMOURS 

The  peritoneum  is  often  involved  secondarily  by  malignant  growths, 
but  is  rarely  the  seat  of  a  primary  tumour.  It  is  said  to  be  sometimes 
the  seat  of  a  primary  endothelioma  and  of  colloid  carcinoma.  Other 
neoplasms,  described  as  peritoneal  tumours,  such  as  lipomas,  are  in 
reality  connective-tissue  tumours  of  the  retroperitoneal  tissues. 

Carcinoma  and  sarcoma  of  the  gastro-intestinal  tract,  uterus, 
ovaries,  and  biliary  passages  often  involve  the  peritoneum,  the  affec- 
tion taking  the  form  of  nodules  of  growth  of  various  sizes  every- 
where studding  the  serous  membrane,  and  involving  in  particular  the 
omentum,  which  tends  to  become  rolled  up  into  cake-like  masses, 
especially  in  the  upper  part  of  the  abdomen.  The  growth  may  consist 
of  hard  nodules,  but  is  sometimes  of  gelatinous  consistency. 

Effusion  of  fluid  into  the  peritoneal  cavity  is  the  rule,  the  fluid  being 
clear  or  straw-coloured  and  often  blood-stained. 

The  symptoms  of  such  peritoneal  involvement  by  malignant  growth 
are  usually  overshadowed  by  those  of  the  primary  tumour.  Sometimes, 
however,  the  primary  growth  is  small  and  so  situated  as  to  produce 
no  symptoms,  in  which  case  those  of  the  peritoneal  involvement  will 
predominate.  The  existence  of  ascites,  together  with  the  presence  of 
nodules  or  large  masses  palpable  on  abdominal  examination,  in  a 
patient  of  or  beyond  middle  age,  would  point  to  the  possibility  of 
intraperitoneal  carcinomatosis.  Similar  cases  of  sarcomatosis  occur  in 
children  and  young  people,  and  such  a  condition  may  be  very  difficult 
to  distinguish  from  tuberculous  peritonitis  {see  above). 

The  treatment  can  only  be  symptomatic. 

HYDATID    CYSTS 
These  cysts  sometimes  arise  primarily  in  the  omentum.     Multiple 
hydatid    cysts  occasionally  result  from   rupture   into   the    peritoneal 
cavity  of  a  primary  cyst  in  the  liver  or  elsewhere. 


PKKITONKA1.     AIFKCTIONS 

MESENTERIC    CYSTS 

Apart  from  hydatids,  the  origin  <>f  mesenteric  obscure. 

They  are  usually  unilocular,  contain  clear  ot  milky  tluiil.  and  may 
attain  a  very  large  size.  Possibly  traumatism  accounts  tor  a  certain 
number  of  the  eases,  though  it  is  more  likely  that  the  injury  merely 
calls  attention  to  a  cysl  which  had  previously  caused  no  symptoms. 

The  presence  of  a  freely  movable  painless  tumour  is  usually  all  that 
the  clinical  picture  presents,  though  indefinite  pain  or  intestinal  dis- 
turbance may  call  attention  to  the  disease.  The  diagnosis  is  usually 
only  made  with  any  certainty  by  exploratory  operation. 

Treatment. — Removal  by  means  of  an  incision  through  the  over- 
lying mesenteric  peritoneum,  with  due  regard  to  the  position  of  the 
intestinal  blood-vessels,  is  the  most  satisfactory  method.  When  the 
c  vst  cannot  be  so  shelled  out  without  risk  of  damage  to  the  blood  supply 
of  the  overlying  or  adjacent  intestine,  it  may  be  brought  up  to  the 
abdominal  wound  and  opened,  the  lips  of  the  incision  in  the  cyst  being 
sutured  to  the  abdominal  wall  and  a  tube  or  gauze  drain  inserted. 

///.  ASCITES 

Any  non-inflammatory  collection  of  serous  fluid  in  the  peritoneal 
cavity  is  called  ascites.  It  is  the  result  of  such  circulatory  disturbances 
as  arise  from  cardiac  or  pulmonary  disease  ;  from  portal  obstruction 
of  hepatic  origin,  such  as  cirrhosis  ;  or  from  renal  disease.  It  is  there- 
fore not  a  disease  of  the  peritoneum,  but  a  secondary  transudation  of 
fluid  into  the  peritoneal  cavity  symptomatic  of  disease  elsewhere. 
Its  symptoms  and  treatment  will  therefore  be  found  dealt  with  in  the 
various  articles  devoted  to  those  causes. 

For  chylous  ascites,  see  under  Lymphatic  System,  Vol.  III.,  p.  84. 

BIBLIOGRAPHY 

Box.  C.  R.,  Lancet,  March  26,  1910. 

Box  and  Eccles,   Clinical  Applied  Anatomy.    London,  1906. 

Buxton  and  Torrey,  Joum.  of  Med.  Research,  xiv.  5. 

Durham.  H.  E.,  Med.-Chir.   Trans.,  London,  lxxx.   191. 

Dudgeon  and  Sargent,  Bacteriology  of  Peritonitis.     London,  1905. 

Gohn,  A..  Wien.  Uin.  U'och.,  1904,  xvii.  207. 

Lennander,  Mittheil.  Grenz,,  L902. 

MacCallum,  Johns  Hopkins  Hosp.  Bull.,  1903,  xiv. 

von  Mikulicz.  Cavendish  Lecture,  1904. 

MuscateUo,  Virchows  Arch.,  cxlii. 

Ramstrom,  Inaug.  Dissert.,  Wiesbaden. 

Veillon  et  Zuber,  Arch,  di  Mel.  Exper.,  July,  1898. 


HERNIA 

By   LAWRIE  McGAVIN,   F.R.C.S.Eng. 

Structure  of  a  hernia — With  certain  exceptions  a  hernia 
consists  of  (1)  a  sac,  (2)  its  coverings,  and  (3)  its  contents. 

In  some  hernias,  to  be  described  later,  the  sac  is  partially  or  wholly 
absent,  and  in  some,  although  present,  it  may  be  devoid  of  contents 
from  time  to  time. 

The  hernial  sac  consists  of  peritoneum,  and  is  either  present  at 
birth,  or  is  formed  subsequently  as  the  result  of  pathological  changes 
in  the  abdominal  wall.  It  is  usually  described  as  having  a  neck,  a 
body,  and  a  fundus. 

The  neck  is  that  part  which  occupies  the  aperture  through  which 
the  hernia  escaped.  It  is  commonly  narrow,  being  constricted  by  the 
surrounding  tissues,  and  when  unoccupied  is  flattened  from  before 
backwards.  Occasionally,  however,  it  is  the  widest  part  of  the  sac. 
In  its  earliest  condition,  the  peritoneum  of  the  neck  resembles  that 
from  which  it  springs  ;  it  is  quite  free  from  the  surrounding  struc- 
tures, and  is  lined  by  normal  glistening  endothelium.  In  children  it 
is  very  thin,  and  in  all  inguinal  or  femoral  hernias  the  posterior  wall 
is  thinner  than  the  anterior. 

The  body  is  usually  wider  than  the  neck,  and  is  at  first  unilocular. 
Subsequently  it  may  enlarge  to  remarkable  dimensions  and  become 
altered  in  character.  A  sac  may  exist  which  has  never  been  occu- 
pied by  contents,  in  which  case  it  rarely  attains  to  great  size  and 
may  retain  the  original  character  of  the  parietal  peritoneum. 

The  fundus,  or  extreme  end,  is  usually,  though  not  always,  the 
oldest  part  of  the  sac.  Since  the  iliac  peritoneum  is  more  readily 
dragged  down  than  the  parietal,  there  is  in  inguinal  and  femoral 
hernias  a  tendency  for  the  original  point  of  protrusion  to  lag  behind ; 
the  fundus  may  thus  be  formed  from  the  peritoneum  which  was 
derived  from  the  iliac  fossa. 

Formation  of  hernial  sacs. — Hernial  sacs  may  have  their 
origin  as — 

1.  Preformed  (congenital)  sacs. — The  opinion  is  becoming 
more    general   that   many   sacs,    hitherto    looked   upon   as   acquired, 

58o 


FORMATION   OF   HERNIAL  SACS  581 

tie  in  reality  congenital  diverticula.  This,  as  pointed  <>m  !>v  Hamilton 
Russell,  is  especially  the  case  with  femoral  hernias,  and  probahh 
applies  to  the  inguinal  variety  as  well. 

The  sacs  of  undoubtedly  oongenitaJ  origin  are  those  which  occur 
(a)  into  tin- patent  vaginal  process  in  the  male,  (h)  into  tin-  paten! 
eanal  of  Nuck  in  the  female,  (r)  at  the  patenl  umbilical  ring  w  the 
infant.     These  are  considered  later. 

2.  Distension  diverticula  (acquired  sacs).'— These  occur  as 
the  result  of  limscular  weakness  at  certain  sites  in  the  abdominal  wall, 
assisted  by  forced  expiratory  efforts  which  repeatedlv  raise  the  intra- 
abdominal pressure.  They  are  commonly  thicker  in  the  wall  and 
more  adherent  at  the  neck  than  the  sacs  of  congenital  origin,  ami  are 
often  wide-mouthed  from  the  first,  especially  when  they  are  of  the 
variety  met  with  in  direct  hernia;  they  are  frequently  multilocular, 
and  are  rarely  empty. 

3.  Traction  diverticula. — For  the  formation  of  a  sac  by  the 
constant  drag  of  a  tumour  attached  to  some  portion  of  the  peritoneal 
surface,  the  action  of  gravity  is  necessary ;  and  for  this  reason  such 
sacs  are  rarely  seen  in  any  position  other  than  the  pelvic  floor.  Sacs 
are.  however,  formed  in  the  inguinal  region  by  the  dragging  of  tumours 
of  the  cord  or  testis,  or  by  the  weight  of  large  hydroceles.  Lipomas 
of  the  spermatic  cord  are  often  found  at  the  fundus  of  a  sac,  suggesting 
the  possibility  that  the  sac  has  arisen  first  by  traction  and  then  by 
distension. 

4.  Downward  displacement  of  the  peritoneum. —  This 
method  of  formation  is  rare  ;  it  is  usually  seen  in  cases  of  hernia 
associated  with  general  enteroptosis  (Glenard's  disease),-  and  results  in 
the  presence  of  a  complete  sac  only  at  the  commencement  of  the 
trouble,  for  in  time  the  iliac  peritoneum  slips  down,  and  what  was 
the  posterior  wall  of  the  sac  becomes  first  the  fundus  and  then  the 
anterior  wall,  the  posterior  wall  now  being  deficient,  and  its  place 
being  taken  by  the  down-slipping  caecum  on  the  right  side,  or  the 
sigmoid  on  the  left ;  a  partial  sac  is  thus  eventually  formed  (Fig.  457). 
Such  sacs  are  more  often  met  with  in  direct  than  in  oblique  inguinal 
hernias. 

The  congenital  sac. — Prior  to  birth,  two  well-recognized 
processes  of  peritoneum  exist,  which  should  be  obliterated  when 
the  infant  is  born.  These  are  (1)  the  umbilical  process,  and  (2)  the 
funiculo-vaginal  process  of  the  testis  in  the  male,  or  the  canal  of 
Nuck  in  the  female. 

The  first  rarely  persists  long  ;  containing  at  birth  a  small  coil 
of  ileum  in  connexion  with  Meckel's  diverticulum,  it  commonly 
closes  within  a  few  days.  Remaining  unobliterated,  however,  it 
forms  the  sac  of  a  "  congenital  umbilical  hernia." 


582 


HERNIA 


The  second  is  more  important.  In  both  sexes  the  inguinal 
canal  is  occupied  shortly  before  birth  by  a  tubular  process  of 
peritoneum,  which  passes  into  the  scrotum  of  the  male,  forming 
the  processus  vaginalis  of  the  testis,  and  in  the  female  into 
the  labium  majus,  forming  the  canal  of  Nuck.  The  latter  should 
be,  and  usually  is,  entirely  obliterated ;  exceptionally  it  remains 
patent  and  forms  the  sac  of  a  "  congenital  hernia  of  the  canal 
of  Nuck."  The  former  should  be  obliterated  as  far  as  the  testis, 
the  remainder  forming  the  tunica   vaginalis  of  that  organ.     If  the 


Fig.  442. — Sac   of   hernia  into 
processus  vaginalis. 

r.v.,  Processus  vaginalis  ;  o.r.,  pubes  ; 
R.,  rectus  muscle. 


Fig.  443. — Sac  of  hernia 
into  funicular  process. 

H.s.,  Hernial  sac;   T.v..   tunica  va- 
ginalis ;     o.h.,   pubes;     r.,    rectus 
muscle. 


process  remains  patent  in  its  whole  length  and  at  any  time  contains 
viscera,  the  sac  thus  formed  is  that  of  a  "  congenital  hernia  of  the 
vaginal  process  "  (Fig.  442).  If  the  process  is  obliterated  at  the  upper 
pole  of  the  testis  but  in  free  communication  with  the  peritoneal  cavity 
above  this  point,  the  sac  is  that  of  a  "  congenital  hernia  of  the  funicular 
process"  (Fig.  443).  Two  other  forms  of  congenital  sac  are  met  with, 
and  are  known  as  "  infantile "  and  "  encysted  infantile."  In  the 
first,  there  is  what  looks  like  an  acquired  sac  immediately  behind, 
and  bulging  into,  the  sac  of  a  congenital  hernia  of  the  vaginal  process 
or  funicular  process  (Fig.  444).  In  the  second,  the  neck  of  the  vaginal 
process  would  seem  to  have  been  obliterated  only  at  the  internal 


IIKRNIAL    SACS 


583 


abdominal  ring,  by  a  septum  which,  having  been  stretched  and  forced 
downwards,  lias  formed  a  second  sac  dependenl  within  the  lumen  of 
the  first  (Fig.  445).  A  better  term  for  the  firsl  of  these  sacs  would 
be  " retrofunicular,"    and    for    the    second    " intrarunicular."    It   is 

doubtful  if  the  second  sac  in  the  first  of  these  forms  is  really  of 
congenital  origin. 

The  congenital  sac  differs  but  Blightly   from  the  acquired  sac  in 
n-     general     appearance;     it   is,   however,   usually   narrower   at    the 


Fig.  444. — Sac  of   infantile 
hernia ;    common  variety. 

i'. v.,   Processus   vaginalis  ;    h.s..  hernial 
sac;  o.i\,  pubes  ;  r.,  rectus  muscle. 


Fig.  445.— ^Sac  of  encysted 
infantile  hernia. 

P.V.,    Processus    vaginalis  ;    H.s.,    hernial 
sac;  O.P.,  pubes;    r.,  rectus  muscle. 


neck,  less  adherent  to  its  surroundings,  and  freer  from  thickening 
and  cicatrization  of  its  walls ;  it  is  frequently  empty  or  contains 
only  fluid. 

Contents  of  hernial  sacs. — In  a  reducible  hernia  the  con- 
tents may  vary,  but  in  an  irreducible  one  they  are  usually  constant. 
The  commonest  content  is  the  omentum,  owing  to  its  weight,  length, 
mobility,  and  lobulated  character,  which  facilitate  its  engagement  in 
the  hernial  orifices.  Occasionally  its  free  margin  becomes  adherent  to 
the  posterior  edge  of  the  aperture,  and  a  part  above  is  invaginated 
into  the  sac  so  as  to  form  an  omental  lining  or  "  omental  sac  "  ;  the 
recognition   of  this   condition   is  important  during   operation,  owing 


584  HERNIA 

to  the  danger  of  including  a  contained  knuckle  of  gut  when  ligating 
the  omentum. 

Next  in  frequency  is  the  bowel  itself.  The  part  most  commonly 
involved  in  inguinal  and  femoral  hernias,  especially  on  the  right  side, 
is  the  lower  part  of  the  ileum  ;  on  the  left  side,  the  ilio-pelvic  colon  is 
often  found.  Very  rarely  the  intestinal  canal  of  one  side  will  trespass 
into  a  sac  of  the  opposite  side.  Thus,  sigmoid  is  at  times  found  on 
the  right  side  (Eccles,  Kelly,  Griffiths),  and  appendix,  csecum,  and 
ascending  colon  have  been  found  in  a  sac  on  the  left  (Owen  Richards). 
Such  cases  are  of  extreme  rarity,  and  suggest  either  general  enteroptosis, 
elongation  of  the  mesocolon,  or  transposition  of  viscera. 

The  presence  of  the  vermiform  appendix  in  right-sided  sacs  has 
been  frequently  noted,  at  times  in  a  state  of  acute  inflammation.  I 
have  met  with  such  a  condition  in  4  per  cent,  of  cases. 

A  Meckel's  diverticulum  may  be  met  with  in  inguinal  sacs,  and 
may  be  mistaken,  when  much  atrophied,  for  an  adhesion  band  ;  the 
discovery  of  its  true  nature  is  thus  a  matter  of  some  importance. 

The  ovary  and  Fallopian  tube  are  met  with  occasionally  in  inguinal 
and  even  femoral  sacs,  the  tube  being  often  adherent  at  its  fimbriated 
extremity.  I  have  also  found  a  small  pedunculated  fibro-myoma  of 
the  uterus  in  an  inguinal  sac. 

Although  the  bladder  is  more  commonly  found  in  the  extra- 
peritoneal varieties  of  hernia,  a  process  of  it  may  present  in  the 
sac  of  an  inguinal  or  a  femoral  hernia. 

The  sac  of  an  umbilical  hernia  rarely  contains  anything  except 
omentum,  transverse  colon,  and  mesocolon ;  it  may,  however,  contain 
small  intestine  or  a  Meckel's  diverticulum. 

Fluid  may  be  found  in  hernial  sacs,  and,  unless  due  to  ascites, 
points  to  some  local  irritation  of  the  sac  or  its  contents.  Thus,  it 
is  seen  constantly  in  strangulation,  or  where  strangulation  has 
undergone  spontaneous  resolution  ;  it  may  also  be  associated  with 
injury  to  the  sac,  with  pressure  by  a  badly  fitted  truss,  or,  at  times, 
with  localized  tuberculous  or  malignant  disease  of  the  sac  or  its 
contents. 

Loose  bodies  may  be  found  in  hernial  sacs,  usually  in  the  form 
of  calcareous  or  fibro-cartilaginous  masses  varying  in  size  from  a  pea 
to  a  horse-bean  ;  these  are  usually  detached  appendices  epiploicae 
which  have  undergone  secondary  histological  change. 

Diagnosis  of  hernial  contents. — The  presence  of  bowel 
is  usually  determined  from  the  elastic  character  of  the  tumour,  the 
gurgling  of  fluid  and  gas  when  it  is  handled,  the  resonance  to  per- 
cussion, the  occurrence  of  visible  peristalsis,  and  the  plastic  sensation 
due  to  the  presence  of  faeces. 

Recurrent  attacks  of  pain  and  tenderness  in  a  sac,  especially  if 


DIAGNOSIS   OF   HERNIAL   GONTKNTS  585 

accompanied  by  pyrexia  and  vomiting,  but  in  the  absence  of  definite 
Bigns  of  strangulation,  should  suggest  the  presence  of  an  inflamed 
appendix.  Its  presence  may  at  times  be  diagnosed  by  palpation, 
from  the  peculiar  shape  of  the  organ,  and  from  the  tenderness  on 
pressure  being  referred  to  Mc  Barney's  point,  or  to  the  umbilicus. 

Omentum  in  the  sac  gives  rise  to  a  spongy,  lobulated  mass  of  ill- 
defined  outline,  usually  irreducible,  dull  to  percussion  throughout 
the  length  of  the  inguinal  canal,  although  in  the  scrotum  there  may 
be  areas  of  resonance  which  are  due  to  bowel.  It  lacks  the 
tenseness  and  rounded  character  of  hydrocele,  and  the  plastic 
character  of  heces. 

The  presence  of  an  ovary  is  generally  indicated  by  tenderness 
and  enlargement  of  the  hernia  coincident  with  each  menstrual  period, 
irregularity  of  these  periods,  some  displacement  of  the  uterus  to  the 
side  of  the  hernia,  and  absence  of  the  ovary  of  that  side  when  a 
bimanual  examination  is  made.  In  either  femoral  or  inguinal  hernia 
its  characteristic  shape  and  sensation  on  pressure  may  be  elicited  in 
the  quiescent  period. 

Hernias  which  contain  csecum,  colon,  or  sigmoid  are  usually  very 
large  with  wide  necks,  contain  faeces  from  time  to  time,  and  are  often 
associated  with  constipation  and  incarceration. 

It  is  not  always  possible  to  be  certain  of  the  presence  of  the  bladder 
in  the  sac  of  a  hernia,  since  only  a  small  part  of  its  wall  may  be 
involved,  but  it  should  be  suspected  in  all  cases  of  direct  inguinal 
and  in  femoral  hernia  accompanied  by  urinary  symptoms,  whether 
in  the  way  of  frequency,  pain,  strangury,  or  unexplained  cystitis ; 
and  in  cases  where  an  overfull  bladder  is  associated  repeatedly  with 
an  increase,  and  micturition  with  a  decrease,  in  the  size  of  the  hernia. 
In  femoral  hernia  the  bladder  should  never  be  forgotten,  whether 
symptoms  are  present  or  not,  since  it  is  frequently  found  at  operation 
without  any  external  evidence.  Where  doubt  exists,  it  may  be  cleared 
up  by  the  passage  of  a  sound  per  urethram,  after  the  bladder  has  been 
emptied  ;  it  may  thus  be  possible,  especially  in  the  female,  to  direct 
the  beak  of  the  sound  into  the  diverticulum  in  the  sac,  and  so  avoid 
an  accident  during  operation. 

Coverings  of  the  sac. — These  naturally  depend  on  the 
variety  of  hernia  in  question,  and  will  be  discussed  as  each  variety  is 
considered. 

Secondary  changes  in  the  sac — Although  at  first  a 
simple  protrusion  of  almost  unaltered  peritoneum,  the  sac  does  not 
long  remain  in  this  condition ;  it  is  influenced  especially  by  pressure 
and  irritation  from  without,  and  by  the  character  and  weight  of  its 
contents.  At  first  it  is  thin,  avascular,  usually  unilocular,  and  easily 
reducible   into   the    abdomen ;     but   with   the    constantly   increasing 


586  HERNIA 

weight  of  its  contents  it  becomes  stretched,  and  tends  to  grow  in 
length  rather  than  in  width,  provided  no  pressure  is  brought  to  bear 
upon  it  from  without. 

1.  Thickening  of  the  walls. — This  increase  in  size  demands 
an  increase  in  nutrition  ;  the  sac  soon  becomes  adherent  to  the 
surrounding  structures,  develops  new  vessels  on  its  outer  surface, 
and  becomes  very  much  thicker ;  in  hernias  of  large  dimensions 
and  long  standing  the  walls  may  measure  as  much  as  an  eighth  to  a 
quarter  of  an  inch  in  thickness,  and  assume  the  consistence  of  the 
pericardium.  These  changes  are  chiefly  seen  in  irreducible  omental 
hernias,  where  the  omentum  has  become  widely  adherent  to  the  sac 
wall,  which  thus  receives  a  blood  supplv  from  within  as  well  as  from 
without.  Thickening  is  also  favoured  by  the  chronic  congestion 
produced  by  the  pressure  of  an  ill-fitting  truss  upon  the  veins  about 
the  neck  of  the  sac. 

2.  Thickening  below  the  neck. —  The  changes  above  mentioned 
are  frequently  most  marked  just  below  the  neck  of  the  sac,  especially 
if  a  truss  has  been  worn,  this  part  becoming  densely  adherent  to  the 
tissues  about  it  and  often  developing  into  an  almost  fibro-cartilaginous 
ring,  while  the  true  neck  and  the  structures  composing  the  inguinal 
or  femoral  canal  become  thinned  out  and  matted  together  owing  to 
the  pressure  of  the  truss.  In  such  cases  the  omentum  in  the  sac  is 
usually  adherent  to  the  entire  circumference  of  the  neck. 

3.  Cartilaginous  and  calcareous  degeneration.  —  These 
are  only  met  with  in  hernial  sacs  of  large  dimensions  and  long 
standing.  The  areas  of  degeneration  are  usually  discrete,  and  seldom 
involve  the  entire  sac  wall. 

4.  Obliteration  of  the  neck. — Occasionally  a  sac  containing 
fluid  is  seen  in  which  the  original  communication  with  the  abdominal 
cavity  has  been  cut  oft.  The  cause  is  to  be  sought  in  some  antecedent 
inflammation  at  the  neck  of  the  sac  by  which  the  passage  has  been 
sealed.  The  pressure  of  a  truss  on  a  strand  of  unreduced  omentum 
may  be  the  cause  ;  occasionally  the  obliteration  appears  to  be  spon- 
taneous, no  truss  having  been  worn.  Such  a  fortunate  result  is  only 
possible  in  sacs  having  very  narrow  necks  ;  the  condition  is  termed 
"  hydrocele  of  a  hernial  sac." 

5.  Cysts  in  hernial  sacs. — In  certain  cases  a  hernial  sac  will  be 
found  to  include  one  or  more  cysts  containing  fluid,  giving  the  im- 

rion  of  a  second  sac  within  the  first.  These  cysts  will  be  found  to 
have  no  connexion  with  the  abdominal  cavitv  or  the  tunica  vaginalis. 
They  are  developed  in  or  between  the  sac  walls  and  its  coverings. 
They  are  commonly  due  to  lymphatic  dilatation  or  to  subserous 
effusions  resulting  from  irritation  or  injury,  and  have  no  pathological 
importance. 


SECONDARY   CHANGES  5«7 

6.  Acute  inflammation. — This  is  rarely  seen  excepl  In  the  8a 
very  large  irreducible  hernias;  i1  is  of  the  nature  of  a  localized  peri- 
tonitis, is  predisposed  to  by  direct  injury,  and  usually  results  in 
resolution  with  the  formation  of  extensive  adhesions  between  the 
sac  and  its  contents.  At  times  it  may  give  rise  to  strangulation  of 
these  contents,  or  may  progress  to  complete  slouching  or  gangrene. 
li  i-  especially  prone  to  occur  in  the  victims  of  Bright's  disease,  in 
whom  the  prognosis  is  consequently  very  unfavourable. 

7.  Loculation. — Although  due  at  times  to  congenital  abnormality, 
the  formation  of  secondary  loculi  in  hernial  sacs  is  also  seen  as  the 
result  of  inflammation  about  the  inguinal  and  femoral  regions,  and 
is  an  almost  constant  feature  of  umbilical  hernias  of  any  size.  It  is 
especially  prone  to  occur  in  recurrent  hernias  of  rapid  formation. 
The  presence  of  omentum  densely  adherent  to  the  sac  wall  below 
the  neck  may  compel  the  wall  above  the  adhesion  to  bulge  laterally 
through  the  separated  fibres  of  its  coverings.  Thus  the  original  sac 
may  have  one  or  more  secondary  loculi,  opening  usually  near  the 
neck,  and  often  as  large  as,  or  even  larger  than,  the  parent  sac. 

8.  Localized  disease. — Although  extremely  rare,  cases  have  been 
reported  of  the  presence  of  disease  apparently  confined  to  hernial 
sacs.  I  have  met  with  three  such  cases  :  in  two  elderly  men,  masses 
in  the  fundi  of  the  sacs  proved  on  section  to  be  spheroidal-celled 
carcinomas  ;  in  the  third,  a  middle-aged  man,  an  apparently  localized 
tuberculous  mass  was  found. 

Secondary  changes  in  the  coverings. — In  some  cases 
the  coverings,  owing  to  very  rapid  increase  in  the  size  of  the 
hernia,  become  extremely  thin,  their  fibres  being  widely  separated 
and  atrophic,  the  common  condition  in  umbilical  hernia ;  on  the 
other  hand,  those  which  develop  slowly  and  steadily  frequently 
undergo  marked  hypertrophy,  the  muscular  coverings  especially 
appearing  as  a  definite  thick  layer.  In  such  cases  the  blood  supply 
is  markedly  increased,  and  large  vessels  are  seen  ramifying  over  the 
surface  of  the  sac,  while  the  coverings  are  matted  together  and  often 
densely  adherent. 

Occasionally,  in  very  large  umbilical  and  ventral  hernias,  wdiose 
coverings  are  atrophic,  the  skin  at  the  most  dependent  part  becomes 
cedematous  and  inflamed,  and  a  slough  appears,  or  what  is  more 
common,  a  recurrent  superficial  ulcer.  Such  changes  are  due  to  inter- 
ference with  the  blood  supply  and  to  the  influence  of  gravity. 

Secondary  changes  in  the  contents. — As  regards  the 
omentum,  the  most  noteworthv  changes  are  the  remarkable  and 
often  rapid  increase  which  takes  place  in  its  volume  when  it  remains 
permanently  in  the  sac,  and  its  proneness  to  become  adherent  to  its 
surroundings.     This  increase  is  independent  of  any  general  increase 


588  HERNIA 

in  obesity  of  the  patient,  and  depends  chiefly  on  interference  with 
the  venous  return  from  the  omentum,  since  the  most  marked  examples 
are  met  with  where  this  organ  is  adherent  to  the  neck  of  the  sac  ;  at 
the  same  time  it  is  not  entirely  due  to  oedema,  distension  of  vessels, 
nor  to  intrusion  of  fresh  omentum,  but  in  part  arises  from  actual 
hypertrophy. 

Adhesions  in  hernial  sacs  may  concern — 

1.  The  sac  only. — Fibrous  bands,  the  result  of  old  inflammation, 

are  at  times  found  passing  from  one  side  to  the  other ; 
these  may  subsequently  become  stretched- and  form  "  bridles," 
just  as  they  do  in  the  abdominal  cavity.  Their  only 
surgical  importance  is  that  they  predispose  to  strangu- 
lation, and,  especially  if  they  cross  the  neck,  are  apt  to 
ensnare  a  loop  of  bowel  when  reduction  is  attempted,  thus 
giving  rise  to  one  of  the  varieties  of  "  reduction  en  masse  " 
(p.  644).  They  may  occur  simply  as  elevated  cicatricial  bands 
on  the  inner  surface.  Again,  an  actual  septum  may  be  pro- 
duced by  these  adhesions,  the  sac  being  thus  divided  into 
an  upper  and  a  lower  compartment,  the  latter  of  which, 
filling  with  fluid,  becomes  a  hydrocele  of  the  sac. 

2.  The  sac  wall  and  the  contents. — When  adhesions  occur  between 

these  two  they  commonly  result  from  inflammation  of  the 
omentum.  Bowel  is  rarely  found  adherent  to  the  sac  unless 
affected  by  inflammation  arising  in  the  omentum,  or  unless 
itself  diseased.  Thus  a  loop  of  bowel  containing  tuberculous 
ulcers,  an  appendix  when  inflamed,  or  a  portion  of  large 
bowel  inflamed  as  the  result  of  stercoral  ulceration,  may 
acquire  adhesions  to  the  sac  at  any  point.  Similarly  the 
ovary  and  Fallopian  tube  may  become  adherent  to  the  wall. 

3.  The  contents  alone. — Rarely,  adhesions  occur  in  the  sac  without 

affecting  its  walls.     The  contents  may  be  so  bound  together 

as    to    prevent    reduction,   the    cause   being,    as   before,   the 

presence  of  inflamed  omentum,  etc. 

The  intestine,  when  long  retained  in  a  sac  by  adhesions,  frequently 

undergoes   marked   hypertrophy.     In   certain   cases,    owing   to   some 

constriction  at  the  neck  of  the  sac,  not  sufficient  to  cause  actual 

strangulation,  it  may  become  permanently  narrowed  at  one  or  more 

points  by  a  ring-like  atrophy  of  the  muscular  wall  and  subsequent 

fibrosis  at  these  points. 

In  umbilical  and  ventral  hernias  the  bowel  may  become  adherent 

to  the  thinned-out  cutaneo-peritoneal  sac,  and  may  then  be  affected 

by  the  sloughing  above  mentioned,  a  faecal  or  intestinal  fistula  resulting. 

Occasionally  an  appendix  or  an  ovary  occupying  a  hernial  sac 

undergoes  an  attack  of  acute  inflammation,  and  if  the  presence  of 


ETIOLOGY   OF    HERNIA  580 

these  organs  baa  not  been  diagnosed,  tin-  ease  may  \»-  treated  simply 
as  one  "f  inflamed  Bac,  with  the  resull  thai  an  abscess  forms,  ami  in 
the  one  case  a  fecal  fistula,  ami  in  tin'  other  sloughing  of  the  ovary 
ami  its  tube,  is  the  result. 

Etiology  of  hernia.^ It  has  been  customary  hitherto  to 
divide  all  hernias  into  two  classes,  viz.  (1)  those  dependent  on  some 
arrest  in  the  development  of  the  abdominal  wall  at  or  previous  to 
birth,  ami  therefore  known  as  congenital ;  and  (2)  those  which,  owing 
to  weakening  of  the  abdominal  wall  at  its  most  vulnerable  points 
by  subsequent  strains  ami  injuries,  originate  in  later  life,  and  are 
known  therefore  as  acquired.  Much  doubt  has  been  thrown  on  the 
accuracy  of  the  latter  term  by  Hamilton  Russell,  whose  theory  is 
dealt  with  later  (p.  590). 

Whether  a  hernia  be  congenital  or  acquired,  certain  factors  are 
essential  to  its  formation — (1)  a  weak  spot  in  the  abdominal  wall,  and 
(2)  an  increase  in  the  intra-abdominal  pressure. 

1.  Weak  spots  in  the  abdominal  wall. — Inasmuch  as  fibrous 
tissue  lacks  the  power  of  resistance  to  strain  and  of  recovery  after 
stretching  possessed  by  muscle,  all  areas  in  the  abdominal  wall  that 
depend  for  their  strength  upon  either  aponeuroses  or  cicatrices  are  to 
be  considered  as  weak  spots. 

If  the  entire  abdominal  wall  were  guarded  by  muscular  tissue  alone, 
hernia  would  probably  be  comparatively  rare.  The  naturally  weak 
points  of  the  abdominal  wall  are  as  follows  :  The  inguinal  canal ;  the 
femoral  canal  ;  the  umbilicus  ;  the  median  line  of  the  abdomen  ;  the 
lumbar  (Petit's)  triangle  ;  the  obturator  foramen  ;  the  sciatic  notch  ; 
the  intermuscular  spaces  in  the  levator  ani ;  and  the  c*osto-xiphoid 
interspace. 

2.  Increase  of  intra-abdominal  pressure. — This  is  probably 
only  a  potent  factor — (i)  When  it  is  quickly  developed,  as  in  rapid 
ascites  or  in  general  obesity,  (ii)  When  it  is  sudden,  powerful,  or  inter- 
mittent, as  in  heavy  manual  labour,  in  the  playing  of  wind  instruments, 
in  coughing  or  screaming,  in  repeated  pregnancies  in  weakly  women, 
or  in  the  straining  necessitated  by  phimosis,  stricture,  constipation, 
etc.  (iii)  When  gradual  pressure  is  suddenly  relieved  and  folloived  by 
intermittent  increase,  e.g.  when  large  old-standing  pelvic  tumours  are 
removed  in  asthmatic  or  bronchitic  patients.  Gradual  increase  alone 
has  probably  but  little  influence. 

Defsecation  and  hernia.— Alt  hough  the  squatting  position  during 
defalcation  is  both  natural  and  anatomically  and  physiologically  cor- 
rect, most  modern  conveniences  demand  a  sedentary  posture,  in 
which  the  groins  are  undefended,  the  abdominal  muscles  lack  a  point 
d'appui,  and  consequently  the  effort  required  is  a  serious  tax  on  the 
weak  spots.     If  the  effort  to  support  the  abdomen  on  the  thighs  is 


59o  HERNIA 

made  in  the  sedentary  form  of  convenience,  it  can  only  be  done  by 
lowering  the  head  to  the  level  of  the  knees,  a  dangerous  position  for 
old  people  when  making  any  expulsive  effort.  Both  for  young  and 
old  the  sedentary  posture  is  a  bad  one  and  favours  the  occurrence 
of  hernia  at  the  groins. 

Congenital  theory  of  hernia. — The  production  of  a  hernial 
sac  in  later  life  by  alterations  in  pressure  alone  has  been  questioned 
from  time  to  time,  and  especially  by  Hamilton  Russell,  who  be- 
lieves that  "'  acquired  oblique  inguinal  hernia  in  the  young  subject 
has  probably  no  existence  in  fact."  He  maintains  that,  with  the 
possible  exception  of  some  cases  of  direct  inguinal  hernia,  all  hernias, 
whether  inguinal  or  femoral  (and  probably  ischiatic  and  obturator 
as  well),  are  the  result  of  the  presence  of  congenitally  formed  sacs, 
and  are  not  acquired.  The  grounds  on  which  the  belief  is  founded 
are  (1)  the  results  of  post-mortem  examinations  ;  (2)  the  examina- 
tion of  sacs  removed  by  operation  ;  (3)  the  results  of  operations  in 
which  simple  removal  of  the  sac  constituted  the  entire  procedure  ; 
(•4)  the  accidental  discovery  during  operation  of  preformed  peritoneal 
diverticula  which  had  never  been  occupied  by  a  hernia.  I  have 
found,  in  a  woman  of  47,  both  inguinal  and  both  femoral  canals  patent 
and  occupied  by  such  diverticula,  none  of  which  had  ever  contained 
a  hernia.1  (5)  The  sudden  descent  of  hernias  in  adults  into  sacs  having 
the  anatomical  characters  of  acquired,  but  the  histological  characters 
of  congenital,  sacs  ;  (6)  the  curious  disposition  of  certain  femoral 
sacs  along  the  branches  of  the  femoral  artery  ;  (7)  the  association  of 
hernial  sacs  with  other  congenital  anomalies,  such  as  hypospadias, 
ectopia  vesica?,  congenital  dislocation  of  the  hip,  and  talipes.  Russell 
believes  that  inguinal  sacs  are  simply  diverticula  from  the  original 
processus  vaginalis,  while  the  sacs  found  in  cases  of  femoral  hernia, 
etc.,  are  prolongations  of  the  peritoneal  lining  of  the  abdomen,  which 
are  drawn  out  along  the  course  of  the  branches  of  the  femoral  artery 
during  the  development  of  the  embryonic  limb-buds. 

There  is  much  to  be  said  for  the  congenital  theory  of  hernia,  with 
which  I  am  myself  in  sympathy,  but  space  does  not  permit  of  a  full 
discussion  of  this  subject. 

Clinical  characters  of  hernia. — The  contents  of  her- 
nias, of  whatever  variety,  are  in  nearly  every  case,  in  their  earliest 
stages,  capable  of  being  returned  into  the  abdominal  cavity  by  slight 
pressure,  and  often  disappear  spontaneously  on  the  patient  lying  down. 
Such  hernias  are  known  by  the  term  reducible.  Even  the  sac  in  rare 
cases,  especially  in  children,  can  for  a  period  be  reduced,  but  later, 
becoming  adherent  to  its  surroundings,  it  remains  in  situ,  the  contents 

1  Since  this  was  written  the  patient  has  developed  an  inguinal  hernia  of  the 
right  side. 


IRREDUCIBILITY     \M)   STRANGULATION        591 

only  going  back.     When  the  contents  ran  no  longer  be  returned,  the 
term  irreducible  is  applied  to  the  hernia. 

Causes  of  irreduci bility. — (a)  Adhesions  of  the  contents  to 
the  sac.  (6)  The  matting  together  of  the  contents,  (c)  Lack  of 
mom  inside  the  abdomen  for  the  contents  of  very  targe  and  long- 
standing hernias.  (<l)  The  presence  of  secondary  diverticula  at  the 
neck  of  the  sac,  the  contents  passing  into  these  rather  than  into 
the  abdomen  (see  Interstitial  Hernia,  p.  (510).  (e)  The  presence  of 
any  tumour  in  the  sac.  whether  of  the  contents  or  of  the  sac  itself. 
(/)  The  presence  of  enlarged  inguinal  or  femoral  glands.  {<j)  Increase 
of  intra-abdominal  pressure,  whether  voluntary  on  account  of  tender- 
ness during  manipulation,  or  from  the  presence  of  tumours,  ascites, 
etc.,  in  the  abdomen,  (h)  The  presence  of  faecal  masses,  undigested 
food,  foreign  bodies,  gall-stones,  etc.,  in  the  bowel  contained  in  the 
sac.  Such  a  condition  is  termed  incarceration  ;  when  due  to  impac- 
tion of  faeces  it  is  obviously  only  probable  in  the  large  intestine. 
(i)  Inflammation  or  oedema  of  the  sac  or  its  contents.  (/)  Tumours 
of  the  inguinal  canal  or  of  the  cord  ;  these  are  commonly  either 
fibromas,  lipomas,  or  hydroceles. 

Strangulation. — Occasionally  the  contents  of  a  hernia  become 
strangulated — i.e.  not  only  are  these  contents  irreducible,  but  the 
blood  circulation  and  the  passage  of  flatus  and  faeces  through 
them  is  interfered  with  to  such  an  extent  as  to  result  in  gangrene, 
sloughing,  and  perforation  if  the  condition  is  not  relieved  by  natural 
or  artificial  means. 

Incarceration  can  only  take  place  when  the  sac  contains  bowel, 
whereas  strangulation  may  affect  any  of  the  contents  of  the"  sac. 

Characters  of  incarcerated  hernia. — More  commonly  seen 
in  elderly  men  or  in  women  who  are  stfbject  to  chronic  constipa- 
tion, incarceration  is  almost  confined  to  the  umbilical  and  inguino- 
scrotal  forms  of  hernia.  On  examining  the  hernia,  it  will  be  found 
to  be  globular  in  outline,  heavy,  often  devoid  of  tenderness  and  pain, 
and  having  the  consistence  of  half-dried  putty,  so  that  its  form  can 
be  moulded  by  the  fingers.     It  is,  of  course,  dull  to  percussion. 

It  is  clear  that  if  no  faecal  matter  can  pass  the  site  of  hernia,  a 
time  will  very  soon  arrive  when,  the  whole  of  the  large  bowel  becoming 
full,  the  small  intestine  must  begin  to  regurgitate  its  contentsanto  the 
stomach.  Such  a  condition  is  less  serious  than  actual  strangulation 
only  because  in  it  there  is  no  arrest  of  circulation. 

Frequently,  incarceration  may  persist  for  a  considerable  time,  the 
obstruction  being  partial  in  character  and  partaking  of  the  nature  of 
obstinate  constipation  ;  on  the  other  hand,  it  may  lead  to  strangulation 
from  the  continued  increase  of  pressure  of  the  faecal  contents.  The 
premonitory  signs  of  this  are  the  presence  or  increase  of  umbilical 


59^ 


HERNIA 


pain,  tenderness  in  the  hernia,  distension  of  the  abdomen,  and  the 
presence  of  peristaltic  waves.  Such  signs  are  an  indication  for  early 
operation. 

Anatomical  Varieties  of  Hernia 

Of  the  weak  spots  of  the  abdominal  wall  at  which  hernias  may- 
appear,  the  inguinal  canal  is  by  far  the  most  frequently  involved  ; 
here  two  varieties  of  hernia  are  met  with,  viz.  oblique  and  direct. 

Oblique  inguinal  hernia  (Fig.  446). — Tins  form  of  hernia 
makes   its   exit  at  the   internal   abdominal   ring,    and,  passing   along 


Fig.  446. — Oblique  inguinal  hernia  becoming  inguino-scrotal ; 
also  early  umbilical  hernia. 

the  spermatic  cord  in  the  male,  or  the  round  ligament  of  the  uterus 
in  the  female,  leaves  the  canal  at  the  external  abdominal  ring,  and 
enters,  in  the  former  case  the  scrotum  (Fig.  447),  and  in  the  latter 
the  labium  majus.  The  neck  of  the  sac  thus  has  the  deep  epigastric 
artery  as  its  immediate  internal  relation. 

An  oblique  inguinal  hernia  is  invariably  clothed  by  certain  struc- 
tures known  as  its  "  coverings  "  ;  these  are  best  described  in  order  of 
dissection,  thus  :  (1)  skin  ;  (2)  superficial  fascia  ;  (3)  aponeurosis  of 
the  external  oblique  muscle  and  its  arciform  or  intercolumnar  fibres, 
commonly  called  the  "  external  spermatic  fascia  "  ;  (4)  cremasteric 
fascia,  which  is  simply  the  stretched  fibres  of  the  cremaster  muscle  ; 
(5)  "  internal  spermatic  fascia  "  or  infundibuliform  fascia,  a  finger-like 


OBLIQUE   INGUINAL   HKK.MA 


593 


process  of  the  transversalis  fascia  ;  and  (6)  the  extraperitoneal  fascia 
which  overlies  the  peritoneum.  These  coverings,  with  the  exception  of 
the  oremaster,  which  is  often  hypertrophied  in  old-standing  cases, 
are  not,  as  a  rule,  easily  demonstrable,  being  usually  fused  together. 

In  large  hernias  which  have  existed  for  many  years,  the  internal 
rmg  often  becomes  so  much  distended  that  its  inner  edge  is  shifted 
inwards  ;  similarly,  when  the  hernia  is  of  the  scrotal  variety  the  outer 
edge  of  the  external  ring  becomes  displaced  outwards,  so  that  in  time 
the  two  rings  are  found  to  be  superim- 
posed, and  several  ringers,  or  even  the 
whole  hand,  may  be  passed  into  the  ab- 
domen, the  oblique  character  of  the  hernia 
being  then  apparently  lost.  The  relative 
position  of  the  deep  epigastric  artery, 
however,  will  always  show  the  true  nature 
of  the  hernia  ;  the  position  of  the  struc- 
tures of  the  spermatic  cord  will  also  help 
to  distinguish  it,  for,  although  in  large 
hernias  they  may  be  much  separated  by 
pressure,  they  will  still  lie  deep  to  the  sac. 

A— ociated  with  the  hernia  there  is 
often  a  marked  weakening  of  the  whole 
inguinal  region,  permitting  of  much  bulging 
when  the  patient  stands  up  or  strains,  and 
this  is  especially  common  where  the  hernia 
is  bilateral.  It  may  be  due,  in  elderly 
subjects  with  large  hernias,  to  the  pre- 
sence of  the  hernia  itself,  but  in  young 
subjects  it  is  often  congenital,  and  will  pig  447<_Sac  of  ordinary 
be  found  to   be  caused   by  a  high  origin  inguinal  hernia. 

Of     the     internal     oblique     muscle     and      a      H.s.,  Hennal  sac;  t.v.,  tunica  va- 

defect  in  its  development.  ginaiis;    o.r.,    pubes;    R,  rectus 

...  .  muscle. 

The  progress  of  an  inguinal  hernia 
may  be  comparatively  slow  till  it  reaches  the  external  abdominal 
ring,  from  which  time  the  force  of  gravity  favours  its  descent,  and 
it  rapidly  enlarges,  becoming  "  inguino-scrotal  "  (Fig.  446)  or  "in- 
guino-labial  "  according  to  the  sex  of  the  patient.  Where,  however, 
the  sac  is  that  which  has  been  described  as  "  congenital  vaginal  " 
or  ''  congenital  funicular/'  the  development  of  the  hernia  is  in  some 
cases  actually  immediate,  the  swelling  appearing  suddenly  on  some 
unusual  expirator)'  effort. 

On  arriving  at  the  scrotum,  many  of  these  hernias,  especially  in 
elderly  subjects,  attain  an  enormous  size,  and  cause  great  discomfort 
owing  to  their  weight  and  to  the  fact   that  the  penis  is  frequently 


594 


HKRNIA 


retracted  into  the  mass  so  as  to  disappear  out  of  sight,  micturition  being 
thus  rendered  difficult.  (Fig.  448.)  Such  hernias  are  usually  quite 
irreducible,  frequently  become  incarcerated,  but  are  seldom  stran- 
gulated, owing  to  the  width  of  the  neck  of  the  sac.  The  skin 
over  such  scrotal  hernias  is  frequently  eczematous,  excoriated,  or 
even  sloughy,  owing  to  the  dribbling  of  urine  during  micturition. 

Direct  inguinal  hernia. —  In  this  variety  the  hernia,  in 
place  of  making  its  exit  by  the  internal  abdominal  ring,  leaves  the 
abdomen  internally  to  the  deep  epigastric  artery.  It  thus  enters  the  in- 
guinal canal  through  its  posterior 
wall,  carrying  the  stretched 
fibres  of  the  conjoined  tendon  of 
the  internal  oblique  and  trans- 
versalis  muscles  with  it.  It  then 
takes  the  same  course  as  the 
oblique  variety,  passing  into 
the  scrotum  or  labium  through 
the  external  abdominal  ring.  It 
is  probably  the  only  variety  of 
hernia  which  can  truly  be  said 
to  be  acquired,  and  even  in 
some  cases  it,  too,  is  possibly 
congenital  in  origin.  The  cover- 
ings of  direct  hernia  are  exactly 
similar  to  those  of  oblique,  ex- 
cept that  the  cremasteric  fascia 
of  the  latter  is  replaced  hj  the 
conjoined  tendon  in  the  former, 
and  that  the  term  "  infundibuli- 
form  "  is  not  usually  applied  to  the  transversalis  fascia  here.  The 
sac  lies  posteriorly  to  the  spermatic  cord,  which  it  often  separates 
widely  by  pressure. 

The  following  characters  of  direct  hernia  differentiate  it  from 
oblique  hernia  :  (1)  It  occurs  at  a  later  period  of  life.  (2)  It  is 
slower  in  its  development,  less  frequently  becomes  scrotal,  and  more 
often  rises  towards  the  pubic  region.  (3)  The  neck  of  the  sac  is 
wide,  and  the  hernia  is  often  a  mere  bulging.  (4)  It  is  much  less 
liable  to  strangulation,  and  is  as  a  rule  reducible.  (5)  It  more  often 
contains  small  bowel,  and  not  infrequently  a  portion  of  the  bladder. 
(6)  It  much  more  frequently  results  in  a  very  large  gap  in  the 
abdominal  wall,  and  consequently  more  cases  require  filigree-implant- 
ation for  their  cure.  (7)  It  is  more  commonly  bilateral.  (8)  From 
the  first,  one  or  more  fingers  may  be  passed  directly  back  into 
the  abdomen,  whereas  this  can  only  be  done  in  the  case  of  oblique 


Fig.  448. — Scrotal  hernia  ;  cured  by 
double-filigree  method. 

(Author's  case.) 


INGUINAL  HERNIA  595 

bfernia  of  long  standing  and  large  dimenedons,  and  rarely  even  then 
owing  to  irreducibility.  (9)  In  thin  Bubjects  it  is  at  times  possible, 
with  the  finger  in  the  ring,  to  feel  the  pulsation  of  the  deep  epigastric 
artery  along  the  outer  edge  of  the  neck  of  the  sac. 

Symptoms  and  diagnosis  of  inguinal  hernia. — In  most 
cases  subjective  Bymptoms  are  entirely  absent,  and  the  patient  is 
unaware  of  anything  amiss  until  a.  swelling  is  accidentally  found,  <>r 
attention  is  directed  to  it  by  a  medical  man.  Occasionally  there  is  a 
feeling  of  dragging  in  the  loin  of  that  side,  or  actual  shooting  pain 
caused  by  the  stretching  of  the  fascial  planes  ;  this  may  be  accom- 
panied by  nausea  or  actual  retching,  a  small  piece  of  omentum  or  a 
knuckle  of  bowel  being  nipped  during  sudden  flexion  of  the  thigh. 
There  is  also  a  sense  of  weakness  and  insecurity  in  the  groin  on 
coughing,  which,  even  in  patients  ignorant  of  the  presence  or  nature  of 
a  hernia,  prompts  them  to  support  it  by  manual  pressure.  At  times 
the  presence  of  a  varicocele  at  an  unusual  period  of  life  may  call 
attention  to  the  trouble,  or  the  patient  may  complain  of  gurgling  in 
the  region  of  the  groin  when  making  any  expiratory  effort. 

When  the  hernia  has  reached  the  length  of  producing  an  obvious 
swelling  in  the  groin  and  is  reducible,  the  diagnosis  is  simple  ;  thus, 
the  reduction,  on  applying  pressure,  is  rapid,  and  often  accompanied 
by  a  gurgling  sound  if  bowel  be  present ;  if  the  tips  of  the  fingers  be 
placed  over  the  external  abdominal  ring,  and  the  patient  be  directed 
to  cough,  a  distinct  impulse  will  be  felt,  which  will  be  still  more 
obvious  if  the  little  finger  be  passed  gently  into  the  ring  by  invagi- 
nating  before  its  tip  the  skin  of  the  scrotum.  By  careful  palpation 
the  swelling  will  be  found  to  lie  above  the  level  of  Poupart's  ligament, 
and,  if  it  has  reached  the  external  abdominal  ring,  internally  to  the 
spine  of  the  pubes.  The  empty  sac  may  also  be  felt  as  a  thickening 
in  the  course  of  the  cord. 

Where  the  hernia  is  confined  to  the  inguinal  canal  (i.e.  a  "  bubo- 
nocele ")  and  is  irreducible,  there  is  more  difficulty ;  it  is  then  necessary 
to  differentiate  between  hernia  and  the  following  inguinal  swellings : — 

(a)  Encysted  hydrocele  of  the  spermatic  cord,  or  canal  of  Nuck. — This 
is  firm,  elastic,  usually  of  small  size,  dull  to  percussion,  fixed  in  position, 
and  not  usually  tender.  Using  a  small  frontal-sinus  transillumination 
lamp,  it  wall  be  found  to  be  translucent ;  the  intestine  in  infante, 
however,  is  also  translucent. 

(b)  Retained  testis. — Testes  retained  in  the  inguinal  canal  are  prac- 
tically always  mobile  ;  they  retain  their  characteristic  sensation  of 
tenderness  to  pressure,  and  are  nearly  always  in  association  with  an 
unobliterated  processus  vaginalis. 

(c)  A  lipoma  of  the  spermatic  cord  is  softer,  more  lobulated,  and 
quite  devoid  of  tenderness. 


596  HERNIA 

(d)  A  fibroma  of  the  inguinal  canal  begins  at  the  inner  end  of  the 
canal,  arising  as  a  rule  from  the  sheath  of  the  rectus  abdominis  muscle, 
and  is  very  fixed  and  hard  ;  it  is  painless,  of  slow  growth,  and  of 
rare  occurrence. 

(e)  Glandular  swellings  may  be  recognized  by  their  marked  lobula- 
tion, association  with  other  such  swellings,  rapid  increase  in  size,  and 
tendency  to  break  down,  and  by  the  rarity  with  which  single  glands 
are  affected  here. 

(/)  For  the  differentiation  from  femoral  hernia,  see  p.  598. 

When  the  hernia  is  scrotal,  the  diagnosis  is  again  easy  except  in 
some  cases  of  old-standing  hydrocele  of  the  vaginal  process,  in  which 
reduction  of  the  fluid  is  accomplished  only  gradually,  and  the 
walls  are  too  thick  to  allow  of  translucency.  The  following  points 
will  help  :  The  mass  is  dull  to  percussion  ;  this  means  either  fluid, 
omentum,  or  incarceration.  Fluid  gives  a  smooth,  tense,  heavy  tumour, 
which  in  this  case  will  reduce  very  slowly,  and  as  slowly  return,  and 
which  will  often  give  a  characteristic  "  thrill  "  to  one  hand  when 
flicked  smartly  by  the  finger  of  the  other.  Omentum  is  rarely  reducible 
in  large  hernias,  is  always  lobulated,  and  seldom  tense.  Incarceration 
produces  constitutional  disturbance,  and  has  the  characters  already 
described  {see  p.  591). 

At  times  it  may  be  difficult  to  diagnose  the  presence  of  a  hydro- 
cele of  the  tunica  vaginalis  when  in  association  with  an  irreducible 
omental  scrotal  hernia,  if  both  are  of  long  standing.  There  is,  how- 
ever, generally  a  slight  constriction  to  be  felt  between  the  two,  but 
the  question  is  not  one  of  much  practical  importance.  Such  a  case 
is  shown  in  Fig.  459. 

From  hydrocele  of  a  hernial  sac,  or  from  a  large  vaginal  hydrocele, 
a  hernia  may  be  diagnosed  by  the  fact  that  in  the  former  conditions 
the  swelling  is  localized  to  the  lower  two-thirds  of  the  scrotum,  is 
tense,  elastic,  heavy,  painless,  dull  to  percussion,  devoid  of  tender- 
ness, often  translucent,  and  by  the  cord  being  distinctly  felt  for  a 
space  between  the  upper  end  of  the  swelling  and  the  external 
abdominal  ring. 

Femoral  hernia. — All  structures  which  leave  the  abdomen 
to  pass  into  the  limbs  or  abdominal  wall  carry  with  them  for 
a  short  space  an  investment  from  the  transversalis  fascia  which 
lines  the  abdomen,  and  which  is  gradually  lost  on  their  surface.  In 
the  case  of  the  femoral  vessels  this  investment,  known  as  the  "  crural  or 
femoral  sheath,"  is  well  marked,  and  is  constituted  by  a  downward 
prolongation  of  the  transversalis  fascia  in  front  and  the  iliacus  fascia 
behind.  It  forms  a  funnel-shaped  passage  which  is  subdivided  into 
three  compartments  by  two  fascial  partitions.  The  outer  of  these 
contains  the  femoral  artery,  the  middle  contains  the  femoral  vein, 


FEMORAL    HERNIA  597 

ami    the    inner,    winch    is    known    as    the    femoral    or    crural    canal,    is 

unoccupied  save  for  a  lymphatic  gland  ami  a  small  plug  of  extraperi- 
toneal fat.  It  i>  along  tins  inmr  canal  that  the  contents  <d  a  femoral 
nr  crura]  hernia  descend.     Its  mouth  is  known  as  the  "crural  ring." 

The  anterior  wall  of  the  canal  formed  by  transversalis  fascia  is 
covered  by  the  falciform  "  ligament,"  derived  from  the  iliac  portion  of 
the  Eascia  lata,  whilst  behind  the  posterior  wall  (formed  .d  iliacus  I 
passes  the  pubic  portion  of  t  he  fascia  lata.  The  outer  wall  is  t  he  Beptum 
between  the  canal  and  the  femoral  vein,  whilst  to  the  inner  side  of  the, 
inner  wall  lies  Gimbernat's  ligament  above  and  the  pectineus  muscle 
below  (internally  and  posteriorly).  Overlying  the  lower  end  of  the 
canal  is  the  saphenous  "opening"  in  the  fascia  lata  of  the  thigh; 
this  is  closed  by  the  cribriform  fascia,  which  transmits  some  lymphatics 
and  veins.  The  "crural  ring"  is  closed  by  a  thick  mass  of  areolar 
and  often  fatty  tissue,  the  septum  crurale.  The  immediate  relations 
of  t  his  ring  are  as  follows  : — 

Internally  :  Gimbernat's  ligament,  the  little,  sharp-edged,  triangular 
band  of  fascia  which  tills  in  the  pubic  angle  between  the  inner  end  of 
Poupart's  ligament  and  the  horizontal  ramus  of  the  pubes.  Exter- 
nally :  The  femoral  vein.  Anteriorly :  Poupart's  ligament.  Posteriorly  : 
The  horizontal  ramus  of  the  pubes. 

In  the  course  of  its  descent,  a  femoral  hernia,  leaving  the  abdomen 
through  the  crural  ring,  passes  down  to  the  bottom  of  the  crural  canal, 
and,  taking  the  line  of  least  resistance,  passes  forwards  through  the 
saphenous  "  opening  "  and  appears  as  a  swelling  in  the  groin.  In  its 
passage,  therefore,  it  acquires  the  following  coverings,  which  are 
given  in  order  of  dissection,  viz.  (a)  skin  ;  (b)  superficial  fascia ;  (c) 
cribriform  fascia  ;  (d)  crural  sheath  ;  (e)  septum  crurale  ;  (/)  extra- 
peritoneal fascia  ;    (/j)  sac  of  the  hernia. 

If  Hamilton  Russell's  theory  be  accepted,  the  sac  of  a  femoral 
hernia  is  always  of  congenital  origin,  and  may  occupy  one  of  three 
positions  ;  this  is  due  to  the  fact  that  the  peritoneal  process  from 
which  it  is  formed  is,  in  the  course  of  the  growth  of  the  limb-bud  in 
the  embryo,  drawn  out  from  the  abdomen  along  the  fine  of  the  vessels 
proceeding  from  the  femoral  artery.  Thus  at  times  the  sac  will  be 
found  passing  inwards  along  the  course  of  the  external  pudic,  upwards 
along  that  of  the  superficial  epigastric,  or  outwards  following  the 
superficial  circumflex  iliac  artery.  A  compromise  between  the  latter 
two  positions  is  the  more  common,  the  sac  passing  out  of  the  saphenous 
opening  and  then  turning  upwards  and  outwards  to  a  position  between 
the  two  latter  vessels.  At  times  more  than  one  sac  may  be  present; 
this  is  said  to  be  one  of  the  chief  causes  of  the  recurrence  of  femoral 
hernia  after  operation,  one  of  the  sacs  being  overlooked  at  the  time. 

As  regards  frequency,   femoral  hernia  is  much  more  common  in 


598  HKRNIA 

women  than  in  men,  in  the  proportion  of  6  to  1  ;  it  is,  however,  less 
common  in  women  than  inguinal  hernia,  and  is  usually  met  with  at 
a  rather  more  advanced  age.  The  presence  of  a  femoral  hernia,  owing 
to  the  depth  of  its  origin,  the  receding  angle  of  the  groin,  and  the  fact 
that  it  is  rarely  of  large  size,  is  frequently  overlooked,  and  in  stout 
patients  its  diagnosis  is  not  always  an  easy  matter.  Its  characteristic 
features  are  these  :  It  is  nearly  always  irreducible  from  the  firs!  : 
the  neck  is  always  very  narrow  ;  omentum  is  its  usual  content,  bowel 
being  rarely  found  in  it  except  when  strangulation  reveals  its  presence  ; 
owing  to  the  narrowness  of  the  neck,  strangulation  is  frequent  and 
severe,  the  chief  element  of  clanger  being  found  in  the  presence  of 
the  resistant,  knife-like  edge  of  Gimbernat's  ligament,  which  tends 
to  cut  into  the  surface  of  the  distended  bowel. 

Diagnosis  of  femoral  hernia.  —  1.  The  resemblance  of  a 
femoral  to  an  inguinal  hernia  may  at  times  be  very  close  on  casual 
inspection ;  the  distinction,  however,  depends  on  the  relationship 
of  the  neck  of  the  sac  to  the  spine  of  the  pubis.  On  careful  palp- 
ation, the  spine  will  be  found  to  lie  externally  to  and  below  the 
neck  of  an  inguinal,  and  above  and  internally  to  that  of  a  femoral 
sac  ;  but,  as  the  latter  frequently  passes  upwards  and  overlies  the 
inner  third  of  Poupart's  ligament  and  becomes  to  some  extent  fixed 
there,  careful  examination  is  at  times  required  to  differentiate  these 
hernias.  The  femoral  variety  is  most  closely  simulated  by  the  in- 
guinal bubonocele,  but  in  the  latter  case  reduction  is  effected  by 
pressure  directed  backwards  and  outwards,  whereas  in  the  former  the 
direction  of  pressure  must  be  downwards  ;  very  commonly  the  hernia 
is  not  capable  of  reduction  at  all.  Again,  an  irreducible  bubonocele 
cannot  be  moved  in  any  direction,  while  a  femoral  hernia  is  often 
capable  of  being  pushed  downwards  or  laterally.  On  attempting 
to  pull  a  femoral  hernia  upwards  over  Poupart's  ligament,  it  will  be 
found  to  have  a  firm  anchorage  at  the  saphenous  opening,  and  the 
neck  of  the  sac  will  be  distinctly  felt  if  the  tips  of  the  fingers  are  placed 
just  over  the  opening  and  moved  to  and  fro  across  it  like  the  teeth 
of  a  saw.  I  have  seen  an  irregular  form  of  inguinal  hernia  follow- 
ing an  attempt  at  radical  cure,  in  which  the  sac  descended  beneath 
Poupart's  ligament  into  the  thigh,  appearing  at  the  saphenous  opening  ; 
such  a  condition  can  hardly  be  diagnosed  from  femoral  hernia. 

2.  Enlarged  femoral  glands  are  generally  distinguished  by  being 
(a)  firmer  and  more  lobulated  ;  (b)  often  discrete ;  (c)  commonly 
bilateral  and  in  association  with  other  glandular  enlargements  ;  (d)  if 
not  bilateral,  often  dependent  upon  inflammatory  conditions  of  the 
lower  extremity  ;  (e)  not  accompanied  by  dragging  sensations  in  the 
groin  or  loin ;  (/)  often  movable  in  any  direction,  or,  if  fixed,  lacking 
the  definite  "  neck  "  above-mentioned  ;    (g)  prone  to  a  rapid  enlarge- 


FEMORAL    III  KM  A  :    1)1  V.GNOSIS 

ment,  which  is  accompanied  by  signs  of  softening.  At  bhe  same  time 
they  may  coexisl  with  a  hernia,  and  in  ptoul  patients  are  often 
impossible  to  differentiate  from  thai  condition. 

:;.  Saphena  varus  is  easily  distinguished   by  its  cystic  character, 

and  by  the  fact  thai  n  can  l>c  readily  emptied  by  pressure,  and  by 
compression  of  tin1  vein   below,  the  swelling  refilling  at  once  <>n  the 

release    of    pressure    even    when    the    patient    is    in    the    supine    position 

(when  fluctuation  can  often   he  felt    between  vein  ami  b welling),     h 
is,  further,  almost  always  part  of  a  general  varicosity  of  the  saphi 
vein. 

I.  Aneurysm  of  the  femoral  artery  exhibits  the  characteristic 
expansile  pulsation  which  can  be  arrested  by  pressure  on  the  external 
iliac  artery,  when  the  swelling  will  be,  in  part  at  least,  reduced  without 
gurgling.  It  is.  like  saphena  varix,  cystic  in  character,  and  the  swelling 
reappears  on  the  release  of  pressure.  The  stethoscope  will  reveal  the 
usual  bruit  of  an  aneurysm.  It  is  important  to  recognize  t  he  expansile 
character  of  the  impulse  here,  since  tumours  overlying  the  vessel 
(e.g.  an  omental  hernia,  or  a  mass  of  glands)  may  receive  transmitted 
pulsation  from  it. 

5.  A  psoas  abscess,  when  presenting  beneath  Poupart's  ligament, 
produces  a  swelling  which,  although  appearing  externally  to  the 
vessels,  occupies  much  the  same  position  and  gives  the  same  impulse 
on  coughing  as  a  femoral  hernia.  It  lacks,  however,  the  "  neck,"  is  cystic 
in  character,  is  commonly  associated  with  some  tenderness  or  kyphosis 
of  the  lumbar  spine,  may  be  accompanied  by  wasting,  and  fluctuation 
can  often  lie  made  out  between  the  femoral  swelling  and  that  in  the 
iliac  fossa. 

The  most  important  points  to  remember  with  regard  to  femoral 
hernia  are — (1)  Its  liability  to  early  strangulation.  (2)  The  danger 
of  early  ulceration  of  bowel  when  strangulated.  (3)  The  close  rela- 
tionship to  the  bladder  on  the  inner  (a  diverticulum  from  the  latter 
often  projecting  into  the  sac),  and  to  the  femoral  vein  on  the  outer 
side.  (4)  The  possible  presence  of  the  aberrant  branch  of  the 
obturator  artery,  which  may  pass  along  the  inner  aspect  of  the  neck 
of  the  sac,  and  be  in  danger  of  division  during  the  operation  of 
kelotomy  (see  Strangulated  Hernia,  p.  649). 

The  contents  of  a  femoral  are,  for  all  practical  purposes,  the  same 
as  those  of  an  inguinal  hernia,  except  that  large  intestine  is  less  fre- 
quently, and  the  urinary  bladder  more  frequently,  met  with.1 

Umbilical    hernia. — Except   when  congenital   in   origin,   this 

1  Brunner's  and  Maydl's  statistics  would  seem  to  show  a  greater  frequency 
of  the  bladder  in  inguinal  hernias  ;  the  bladder  is  more  often  seen  as  a  simple 
bulging  in  inguinal  hernia,  but  as  a  true  diverticulum  projecting  into  the  sac  it 
is  conimqner  in  femoral  hernia. 


6oo 


HERNIA 


form  of  hernia  is  rarely  seen  before  middle  life,  and  is  much  com- 
moner after  than  before  40.  Like  femoral  hernia,  it  is  almost  confined 
to  the  female  sex,  and  especially  to  women  who  have  borne  many 
children  and  have  become  obese. 

Six  points  especially  characterize  umbilical  hernia  :  (1)  Its  markedly 
progressive  tendency.  Unlike  the  forms  already  mentioned,  there  is 
almost  no  limit  to  the  size  which  it  may  attain,  and  sacs  are  occasion- 
ally met  with  containing  more  than  half  the  intestinal  contents  of  the 

abdomen.     (2)  The  tendency  to 
widespread    loculation    of    the 
sac.       (3)    The    extensive    and 
rapid   formation    of    adhesions, 
leading    to    (4)    early   irreduci- 
bility.     (5)    The    proneness   to, 
and  dangerous  na- 
ture  of,  strangula- 
tion here.     (6)  The 
difficulty  of  accom- 
plishing   a    radical 
cure. 

Causes    of 
umbilical  hernia. 
— It  is  doubtful  if, 
when    this     hernia 
occurs   in   later  life,  its  sac  is 
ever  "  preformed  "  ;    it  is  prob- 
ably the  result  of  stretching  of 
the    umbilical    cicatrix    bv    a 
Fig.  449.— Umbilical  hernia,  showing;    gradual      increase       of      intra- 
sacculation    in    superficial    fascia       uj  i  in 

(transverse  section)  abdominal  pressure,  or  by  the 

long-continued  intermittent  in- 

L.S.,  Lateral  sacculus  :  i:.,  bowel  ;  o.,  omentum  ;  .  ,  „. 

r.,  rectus  muscle;  v.,  umbilicus.  crease  of  such  pressure.     Thus 

it  is  most  commonly  seen  as 
the  result  of  (a)  repeated  pregnancy  ;  (o)  general  obesity  in  women 
about  the  menopause;  (c)  accumulation  of  ascitic  fluid;  (d)  the 
repeated  strain  thrown  on  the  abdominal  wall  by  the  constant 
coughing  of  chrome  bronchitis  and  emphvsema. 

Clinical  features  of  umbilical  hernia.— At  first  there  may  be 
nothing  seen  externally,  and  the  patient's  attention  may  be  drawn 
to  the  trouble  owing  to  dragging  pain  at  the  umbilicus,  often  accom- 
panied by  nausea  and  flatulent  distension  of  the  abdomen.  There  may 
be  tenderness  in  the  umbilical  region,  and  frequently  the  symp- 
toms are  increased  by  the  act  of  lying  down,  the  explanation  being 
that  if  the  omentum  happens  to  be  adherent  at  this  point  and  the 


UMBILICAL    HLRNIA 


6oi 


Btomach  full,  the  supine  position  results  in  a  falling  back  of  the  latter 
and  a  dragging  upon  the  former.  Where  such  a  "blind  hernia"  is 
present,  it  may  in  a  verv  stoui  paticnl  become  strangulated  without 
the  external  evidence  of  a  swelling  t<>  assist  the  diagnosis.  Owing 
to  the  thickness  and  the  loose  character  of  the  subcutaneous  and 
extraperitoneal  fat  layers,  the  expansion  of  the  hernial  contents  causes 
the  sac  to  bulge  in  various  directions  along  the  lines  of  least  resistance 
into  either  or  both  of  these 
layers  (but  especially  into  the 
former).  The  result  is  that  in 
small  hernias  the  swelling  is 
hidden  in  the  fat,  while  in  large 
ones  there  is  produced  a  two- 
storied  and  complicated  ar- 
rangement of  secondary  sac- 
culi,  radiating  from  the  central 
passage  which  represents  the 
original  sac  (Fig.  449).  If, 
then,  the  hernia  commences 
by  the  protrusion  of  a  lateral 
sacculus  into  the  extraperi- 
toneal, or  into  the  deep  por- 
tion of  the  subcutaneous  layer, 
a  "blind  hernia"  is  produced 
(Fig.  450). 

More  commonly  there  will 
be  noticed  at  the  umbilicus  a 
slight  protrusion  which  trans- 
mits an  impulse  on  coughing. 
In  the  early  stages,  at  least, 
it  can  always  be  easily  re- 
duced, and  the  sharp  edges  of 
the  ring  can  then  be  felt. 

At  a  later  period  these 
hernias  may  assume  gigantic  proportions,  spreading  out  on  either 
side  on  the  abdomen  in  an  ill-defined  and  lobulated  mass,  or  pro- 
jecting directly  forwards,  with  a  tendency,  by  their  own  weight,  to 
sink  down   and   overhang  the   pubes   (Fig.  451). 

At  an  early  stage  the  sac  becomes  adherent  to  the  coverings — peri- 
toneum, aponeuroses,  and  skin  being  welded  into  one  layer  ;  later,  as 
distension  increases,  these  coverings  become  thinned  out,  so  that  the 
intestinal  movements  may  be  observed  through  them.  At  the  same 
time,  extensive  adhesions  are  formed  between  the  contents  themselves 
(the  omentum  being  chiefly  involved)  and  the    sac  walls.      In  very 


Fig.  450.- — "Blind  hernia"  of  umbili- 
cus ;  appendix  epiploica  occupy- 
ing lateral  sacculus  (transverse 
section). 

B.S.,  "Blind"  sac;  l.s.,  lateral  sacculus  ;  a.,  appendix 
epiploica;  c,  colon;  K.,  rectus  muscle. 


6o2 


HKRNIA 


large  pendulous  hernias  the  skin  at  the  mosl  dependent  part  is  often 
reddened,  chronically  inflamed  and  o'deniatous.  and  sometimes  shows 
desquamation     or    ulceration;    whilst    a    broad    band    of    intertrigo 


Fig.  451. — Large  umbilical  hernia,  before  operation. 
(Same  case  as  in  Fig.  45'2.) 

Front  and  side  views. 


Fig.  452. — Large  umbilical  hernia  cured  by  implantation  of 
filigree  measuring  9  in.   x   5  in.     (.  luthors  case.) 


Front  and  side  \  lews. 


appears  at  the  lower  edge  of  the  hernial  neck.  Cases  are  reported 
of  faecal  fistula)  resulting  from  such  ulceration  opening  into  bowel 
in  the  sac. 

The  contents  of  these  hernias  are  usuallv  omentum  and  transverse 


CONGENITAL    UMBILICAL    HERNIA 

oolon,  bul  small  intestine  is  common,  and  stomach  may  be  en- 
countered. Reduction  is  seldom  possible  in  long-standing  cases, 
owing  tit  the  sacculation  already  mentioned,  and  when  strangulation 
occurs  the  prognosis  is  bad  owing  to  the  obesity  of  the  patient  and 
tar  pulmonary  complications  Erequently  associated  with  it. 

The  discomfort  induced  by  a  large  umbilical  hernia  may  be  very 
great;  apart  from  the  constant  drag  on  the  abdominal  contents,  the 
weight  to  be  supported,  the  interference  with  clothing,  and  the  unsight- 
|iness  oi  the  patient's  figure,  there  is  constant  liability  to  attacks  of 
colic,  nausea,  constipation,  or  actual  incarceration  of  the  hernia. 
Little  can  be  done  to  relieve  these  troubles  except  by  operation,  and 
the  risk  of  this  is,  in  very  stout  patients,  considerable. 

Congenital  umbilical  hernia. — It  ia  customary  to  apply 
this  term  to  hernia  at  the  navel  in  infants  and  young  children  when  it 
occurs  in  the  first  few  months  of  life.  Two  forms  of  it  are  described. 
In  one  there  is  intestine  present  in  the  umbilical  cord  at  birth,  retraction 
not  yet  having  taken  place.  Here  the  umbilicus  is  represented  by  a 
circular  gap,  the  spread-out  membranes  of  the  cord  covering  the  loop 
of  intestine,  and  fusing  with  the  skin  at  the  margins  of  the  gap.  In 
such  a  case,  these  avascular  amniotic  membranes  may  become  gan- 
grenous or  may  rupture,  leaving  a  factitious  ectopia  of  the  viscera  ; 
in  most  cases  of  this  kind  death  results  from  septic  peritonitis.  If 
the  membranes  retain  their  integrity  sufficiently  long  to  permit  of 
the  retraction  of  the  bowel,  the  aperture  may  close,  but,  the  cicatrix 
being  weak,  a  hernia  may  develop  at  the  site  of  closure  at  a  later  date. 
In  the  other  form  of  this  hernia  there  is  complete  retraction  of  the 
bowel  at  the  time  of  birth,  but  the  sound  closure  of  the  aperture  is 
delayed.  In  suck  cases  there  will  be  a  bulging  of  the  degenerate  skin 
at  the  umbilicus  on  any  expiratory  effort,  and  subsequently  from  lack 
of  treatment,  or  from  improper  treatment,  a  large  hernia  may  develop. 
To  this  variety  the  term  ''  infantile  "  may  be  applied. 

Although  these  hernias,  when  correctly  treated,  rarely  give  rise 
to  serious  trouble  during  infancy  or  adolescence,  they  do  at  times 
become  strangulated.  In  any  case,  the  cicatrix  of  a  ''  delayed  closure  " 
is  never  so  perfect  as  that  of  the  normal  umbilicus  ;  a  small  peritoneal 
dimple,  which  must  be  regarded  as  a  predisposing  factor  in  the  umbilical 
hernia  of  later  life,  frequently  remains  to  mark  the  site  on  the  visceral 
surface  of  the  parietes. 

Ventral  hernia. — This  may  be  spontaneous  or  acquired,  the 
latter  being  very  much  the  commoner.  Apart  from  umbilical  hernia, 
which  is  only  a  special  form  of  ventral  hernia,  protrusions  of  viscera 
may  occur  in  the  middle  line  above  that  point  (median  epigastric 
hernia),  or  below  it  (median  hypogastric  hernia),  or  may  occupy  the 
entire  length  of  the  linea  alba  (complete  median  hernia).     They  may 


6o4  HERNIA 

also  occur  at  other  points  in  the  abdominal  wall,  but  in  this  case  they 
are  invariably  traumatic  and  are  known  as  "  lateral  ventral  hernias." 

Spontaneous  hernia  (median)  is  rarely  seen  except  in  asso- 
ciation with  large  umbilical  hernias,  where  it  is  usually  an  extension 
downwards  of  the  rupture,  the  lower  segment  of  the  umbilical  ring 
having  given  way  and  the  recti  muscles  having  become  separated. 
Above  the  umbilicus  it  is  more  often  separate,  and  is  sufficiently  rare  to 
suggest  the  possibility  of  a  congenital  origin ;  and  this  is  supported  by 
the  fact  that  it  is  not  usually  seen  in  stout  patients,  and  is  not,  therefore, 
the  direct  result  of  distension.  It  is  perhaps  less  rare  in  men  than 
in  women. 

The  presence  of  subperitoneal  lipomas  has  been  noted  in  many 
instances,  and  is  found  to  be  a  causative  factor  in  some  cases  of  ventral 
hernia,  more  especially  of  the  median  epigastric  variety.  Insinuating 
themselves  into  some  slight  deficiency  in  the  transversalis  fascia,  or 
the  fascia  of  the  posterior  sheath  of  the  rectus  muscle,  these  small 
tumours  gradually  expand  the  cavity  which  they  have  invaded,  and 
by  their  traction  at  times  draw  after  them  the  process  of  peritoneum 
to  which  they  are  attached.  Thus  a  true  hernial  sac  is  formed.  These 
hernias  are  also  found  occasionally  in  the  linea  semilunaris,  and  many 
femoral  hernias  probably  owe  their  origin  to  the  presence  of  the  lipo- 
matous  material  in  the  crural  canal. 

Complete  median  hernia  results  from  wide  separation  of 
the  recti  muscles,  and  is  more  frequently  seen  in  thin  women  who 
have  borne  many  children  than  in  those  who  are  markedly  obese  ; 
it  is  also  seen  in  elderly  men  of  feeble  muscular  development  who 
have  been  subjected  to  hard  manual  labour.  Although  rarely  suffi- 
ciently marked  to  require  operative  interference,  it  is  none  the  less  in 
the  nature  of  a  hernia,  and  may  result  in  considerable  weakness  and 
bodily  discomfort.  It  extends  usually  from  the  ensiform  cartilage 
to  the  pubes,  the  actual  extent  being  easily  ascertained  by  making 
the  patient  raise  the  head  and  shoulders  from  the  supine  position 
without  the  support  of  the  hands.  The  hernia  will  at  once  show  as 
an  elevated  ridge  along  the  linea  alba,  the  actual  gap  being  felt  by 
passing  the  ulnar  edge  of  the  hand  into  it. 

It  is  probable  that  this  condition  originates  in  a  congenital  wideness 
of  the  linea  alba,  and  is  only  aggravated  by  subsequent  exertion,  as 
many  young  subjects  are  met  with  who  exhibit  wide  separation  without 
actual  hernia.  Adhesions,  irreducibility,  and  strangulation  are  never 
met  with  in  this  form  of  hernia,  although  they  occur  in  the  epigastric 
variety. 

Hernia  through  scar  tissue. — Space  does  not  permit  of  a 
discussion  of  the  pathology  of  these  hernias,  but  the  following  points 
should  be  noted  : — 


HERNIA  THROUGH   SCAR  TISSUK  605 

1.  Hernia  never  occurs  through  the  muscular  wall  of  the  abdomen 
except  as  the  result  of  its  conversion  at  some  point  into  scar  tissue. 

2.  This  may  occur  as  the  result  of  suppuration  or  ulceration,  trans- 
verse division  of  the  muscular  fibres  with  subsequent  stretched  union, 
destruction  by  disease,  or  extensive  division  of  the  nerves  supplying 
the  muscles. 

3.  The  whole  thickness  of  the  abdominal  wall  being  converted 
into  scar  tissue,  there  is  no  true  sac  ;  all  the  layers  are  welded  together 
and  the  contents  are  invariably  adherent,  often  densely  so. 

4.  Owing  to  the  alteration  in  structure  of  the  muscle  fibres,  and 
to  the  fact  that  only  by  the  primary  union  of  health v  muscle  can  such 
a  hernia  be  prevented  from  recurring,  these  hernias  are  particularly 
difficult  to  cure,  and  often  necessitate  extensive  and  difficult  plastic 
operations. 

5.  Where  approximation  of  the  above  nature  cannot  be  accom- 
plished, recurrence  can  only  be  prevented  by  converting  the  distensible 
cicatrix  into  material  which  cannot  stretch  [see  Bartlett's  Method, 
p.  629). 

6.  The  period  requisite  for  the  formation  of  a  fully  organized 
cicatrix  produced  by  a  primary  union  is  probably  not  less  than  forty 
to  sixty  days. 

Such  a  hernia  may  follow  the  cicatricial  weakening  of  any  part  of 
the  abdominal  wall  either  by  accident,  by  disease,  or  by  inadequacy 
of  suturing  of  operative  wounds — whether  due  to  faulty  technique  or 
to  the  character  of  the  operation,  as  in  drainage  of  abscesses  or  of 
the  gall-bladder. 

However  produced,  traumatic  ventral  hernia  is,  like  umbilical 
hernia,  constantly  progressive,  crippling  to  the  patient,  and  difficult 
to  repair  ;  it  is  not  amenable,  as  a  rule,  to  any  form  of  truss  or  belt. 
In  spite  of  the  extensive  adhesions  found  in  the  sac,  possibly  because 
of  them,  strangulation  is  seldom  seen,  the  excursions  of  the  contents 
being  very  limited. 

Lumbar  hernia. — A  hernia  appearing  through  the  lateral  aspect 
of  the  abdomen — that  is,  between  the  iliac  crest  and  the  last  rib— is 
known  as  lumbar.  It  is  by  no  means  common,  and  much  doubt  exists 
as  to  the  etiology  of  those  cases  which  are  not  definitely  traumatic. 
In  some  cases  it  is  apparently  congenital,  depending  on  defects  in 
the  musculature,  or  on  absence  of  the  last  rib  ;  in  others  it  follows 
the  development  of  abscesses  arising  in  the  muscular  wall  or  in  con- 
nexion with  caries  of  the  twelfth  rib  ;  the  commonest  form,  however, 
is  that  which  follows  stretching  of  the  scar  resulting  from  operations 
upon  the  kidneys,  especiallv  where  prolonged  drainage  has  been 
employed.  The  congenital  form  may  appear  in  two  different  situations, 
viz.   (a)  behind  the  posterior  axillary  line  and  just  beneath  the  last 


6o6  IIKRNIA 

rib.  and  (6)  anteriorly  to  thai  line  and  immediately  above  the  crest 
of  the  ilium.  The  upper  of  these  hernial  sites  is  the  less  common  of  the 
two  ;  it  is  the  position  frequently  occupied  by  a  lumbar  abscess,  and 
from  this  it  must  be  diagnosed,  since  both  hernia  and  abscess  are 
elastic,  reducible  to  some  extent,  and  give  an  impulse  on  coughing. 

The  lower  hernial  site  is  that  which  is  known  as  "  Petit's  triangle  ::  ; 
it  is  bounded  below  by  the  crest  of  the  ilium,  in  front  by  the  posterior 
margin  of  the  external  oblique  muscle,  and  behind  by  the  anterior 
margin  of  the  latissimus  dorsi  muscle.  The  hernia  is  rarely  more 
than  a  slight  bulging,  and  only  when  there  is  a  distinct  deficiency  in 
the  extent  of  origin  of  these  muscles  can  the  triangle  be  said  to  exist. 
Where  hernia  follows  operations  upon  the  kidneys  the  bulging  will 
occupy  the  whole  space  between  the  ilium  and  the  last  rib.  Owing 
to  the  transverse  division  of  the  muscle  fibres  in  these  operations,  the 
difficulty  of  approximation,  and  the  frequent  necessity  for  drainage, 
this  hernia,  when  it  occurs,  is  extensive  and  very  disabling. 

Of  whatever  variety,  lumbar  hernia  rarely  contains  anything  but 
omentum  and  ascending  or  descending  colon  ;  the  sac  resembles 
that  of  other  ventral  hernias,  being  ultimately  incorporated  with  the 
integuments.  Operative  treatment  is  only  called  for  in  cases  of  hernia 
of  large  dimensions  following  operations  on  the  loins,  and  may  then 
present  considerable  difficulty. 

The  following  four  varieties  of  hernia  are  of  sufficient  rarity  to 
merit  being  considered  as  pathological  curiosities. 

1.  Obturator  hernia — The  protrusion  in  this  case  occurs 
through  the  small  obturator  canal,  the  insignificant  aperture  existing 
at  the  upper  and  anterior  part  of  the  obturator  foramen  for  the  passage 
of  the  obturator  vessels  and  nerve.  Always  of  great  rarity,  it  is 
commoner  in  women  than  in  men,  and  owes  its  importance  to  its  danger 
and  the  difficulty  of  its  diagnosis.  The  hernial  contents,  which  are 
most  frequently  intestinal  (less  commonly  the  colon  and  pelvic  organs), 
in  their  passage  through  the  canal  have  the  obturator  nerve  external 
to  and  above  them,  and,  arriving  outside  the  pelvis,  are  covered  by 
the  pectineus  muscle.  The  hernia  may  never  go  beyond  this  point, 
and  is  very  liable  to  immediate  strangulation  on  its  first  escape.  It 
may,  however,  pass  on  downwards,  forwards,  and  inwards,  and  arrive 
at  the  space  between  the  adductor  longus  and  the  femoral  vessels. 
Here  it  may  at  times  be  felt  as  a  rounded  swelling  rather  deeply 
situated,  and  may  be  confounded  with  a  femoral  hernia  ;  but  it  is 
always  less  mobile,  has  no  palpable  neck,  and  occupies  a  position 
rather  more  internal  than  the  latter. 

The  diagnosis  of  obturator  hernia  is  always  difficult,  so  much  so 
that  it  is  not  infrequently  only  made  in  the  post-mortem  room. 
Strangulation  is  usually  the  first  symptom,  and  in  the  absence  of  any 


GLUTE  \l.    AND   SCIATIC    HERNIA  '"'7 

swelling  a1  any  of  the  hernial  rings  the  condition  may  be  found  at 
an  exploratory  laparotomy;  bul  the  relation  of  the  hernia  to  the 
obturator  nerve,  which  it  often  compresses,  may  give  rise  to  pain 
referred  to  the  hip-  or  knee-joints,  or  along  the  inner  side  of  the  thigh 
and  knee,  or  even  the  calf.  Localized  tenderness  internal  to  the 
femoral  vessels  in  the  presence  oJ  signs  of  obstruction  should 
the  possibility  of  this  condition.  It  should  no1  be  forgotten  that  in 
this  hernia  especially,  as  in  the  two  following  varieties,  a  portion  of 
tin-  lateral  asped  of  tlir  bowel  only  may  lie  involved  (Bichter's  herni 
and  therefore  the  signs  of  obstruction  may  not  be  complete,  fiatm 
passing,  and  even  feeces  at  time-. 

2,  '».  Gluteal  and  sciatic  hernia.  In  the  region  <>f  the 
buttock  there  are  three  apertures  through  which  a  hernia  may 
escape  from  the  pelvis,  viz.  (1)  the  great  sacro-sciatie  notch,  above 
the  pyriformis  muscle  ;  (2)  the  same,  below  that  muscle  (these  two 
hernias  are  known  as  -luteal)  ;  and  (3)  the  lesser  sacro-sciatic  notch, 
when  the  hernia  is  known  as  sciatic.  All  of  these  hernias  are  of  very 
rare  occurrence,  and.  like  obturator  hernia,  are  usually  only  met  with 
when  Btrangulated.  But  they  may  be  recognized  whilst  still  simply 
irreducible,  or  even  in  rare  cases  reducible;  and  in  such  cases  the 
Bwelling  which  is  felt  in  the  gluteal  region  or,  in  the  case  of  the  sciatic 
henna,  just  at  or  below  the  gluteal  fold,  must  be  differentiated  from 
that  produced  by  a  subfascial  lipoma,  a  chronic  abscess  in  connexion 
with  the  hip-  or  the  sacro-iliac  joint,  an  aneurysm  of  the  gluteal  or 
sciatic  vessels,  or  cysts  or  other  tumours  of  this  region 

Pressure  of  the  hernia  on  the  sciatic  nerve  may  cause  local  tender- 
ness or  deep-seated  pain  down  the  back  of  the  thigh,  and  thus  suggest 
sciatica  ;  or  in  the  case  of  the  gluteal  hernia  there  may  be  pain  referred 
to  the  hip-joint.  Owing  to  the  thickness  of  the  coverings  an  impulse 
on  coughing  is  rarely  felt,  and  for  the  same  reason  absence  of  pulsation 
does  not  entirely  obscure  the  possibility  of  aneurysm.  In  aneurysm, 
however,  throbbing  pain  may  be  present,  and,  although  this  might 
suggest  an  acute  abscess,  the  absence  of  constitutional  symptoms 
and  the  duration  of  the  tumour  without  rapid  increase  in  size  would 
negative  the  diagnosis.  Lipomas  are  commonly  devoid  of  pain  or 
tenderness,  and  are  of  such  size  as  to  render  a  mistake  improbable, 
at  least  as  regards  hernia.  Cold  abscesses  not  in  connexion  with 
joints  or  bone  disease  are  also  painless  and  definitely  fluctuating  ; 
otherwise  they  are  only  part  of  a  condition  giving  rise  to  definite 
symptoms.     The  following  points  should  be  remembered  : — 

(1)  All  gluteal  swellings  of  doubtful  origin  should  be  exposed  by 
open  incision. 

(2)  Puncture  by  exploring  needles  should  be  avoided  owing  to  the 
possibility  of  aneurysm  or  hernia. 


6o8 


HERNIA 


(3)  The  possibility  of  the  existence  of  these  rare  hernias  should 
never  be  forgotten  in  obscure  cases  of   intestinal  obstruction. 

(4)  Strangulation  is  usually  tight  and  the  mortality  high,  therefore 
no  time  should  be  lost  in  clearing  up  the  diagnosis. 

These  hernias  may  contain  any  of  the  organs  commonly  found  in 
inguinal  or  femoral  sacs,  and  are  less  frequently  seen  in  children  than 

in  adults  ;  and  the  sexes 
appear  to  be  equally 
affected. 

4.  Perineal  her- 
nia.— This  is  rare.  Pro- 
trusions are  seen  (a)  to 
one  side  or  other  of  the 
perineum  in  the  male, 
or  in  either  labium  in 
the  female  ;  (b)  in  the 
ischio-rectal  fossae,  or  (c) 
through  the  lateral  va- 
ginal wall. 

Passing  between  the 
fibres  of  the  levator  ani 
muscle,  these  hernias  in- 
variably carry  before 
them  a  covering  of  the 
peritoneum  and  the 
pelvic  fascia.  They  are 
of  commoner  occurrence 
in  the  female — owing 
probably  to  the  greater 
width  of  the  pelvis,  the 
presence  of  the  vagina, 
and  the  great  strain  im- 
posed upon  the  pelvic- 
floor  by  childbirth — and 
are  especially  prone  to 
occur  after  rupture  of  the  perineum.  Lacerated  wounds  may  originate 
them,  and  of  these  I  have  met  with  two  cases,  one  following  a  deep 
wound  from  a  broken  chamber  utensil,  and  the  other  a  fall  on  a 
wooden  paling. 

The  diagnosis  is  not  always  easy,  since  these  hernias  are  fre- 
quently closely  simulated  by  pedunculated  subperitoneal  fibromas 
(Figs.  453  and  454).  Such  tumours  are  commonly,  as  in  my  case,  easily 
reducible,  soft,  elastic,  associated  with  a  definite  ring  to  be  felt  in  the 
pelvic  floor,  and  give  a  marked  impulse  on  coughing.     These  fibromas 


Fig.   4.">.'). —  Subperitoneal  fibroma  simulating 
perineal  hernia. 

(From   "Annals  of ' Surgi 


PERINEAL    HERNIA 


609 


may,  indeed,  by  thru-  weighl  and  traction  originate  a  perineal  bernia. 
Perinea]  hernia  has  been  seen  following  trans-sacral  excision  of  the 
rectum.  A  cold  abscess  of  the  isohio-rectal  fossa,  originating  in  disease 
of  t  he  tuber  ischii,  the  ilium,  or  even  the  spine,  may  also  simulate 
this  condition. 

As,  however,  perineal  hernias  almost  always  contain  intestine,  the 
resonance  on  percussion  and  the  gurgling  on  reduction  should  indicate 
the  diagnosis.     Bowel  has  been  opened  on  one  occasion  in  mistake 


Fig.  454. — Perineal  myxo-fibroma  simulating  hernia. 

{Author  s  case.) 

for  an  abscess,  and  excised  in  another  in  mistake  for  a  polypoid  vaginal 
tumour.  As  the  bladder  may  easily  be  contained  in  a  perineal  hernia, 
the  question  should  be  determined  by  the  use  of  a  sound,  the  beak 
being  turned  downwards  into  the  sac,  while  it  is  palpated  from  without. 
Frequency  of  micturition,  desire  accompanied  by  inability  to  perform 
the  act,  or  the  presence  of  constantly  turbid  urine  should  suggest 
the  possibility  of  the  presence  of  the  bladder.  When  appearing  in 
the  vagina  these  hernias  suggest  at  first  sight  the  occurrence  of  a  cyst 
or  an  abscess  of  the  vaginal  wall,  until  they  are  found  to  be  reducible. 

These  hernias  rarely,  if  ever,  become  strangulated,  but  are  very  diffi- 
cult to  cure,  and  are  very  crippling,  from  the  feeling  of  insecurity 
which  characterizes  them. 

Interstitial  hernia — In  certain  cases  of  inguinal  hernia,  espe- 
cially those  of  the  oblique  variety,  there  is  an  irregularity  of  the  sac, 


610  HERNIA 

which  consists  in  the  development  of  lateral  diverticula  in,  or  even 
of  a  complete  congenital  displacement  of  the  whole  sac  into,  the  planes 
of  the  abdominal  wall.  Such  hernias  are  known  as  interstitial  or 
interparietal,  and  are  in  more  than  half  the  cases  in  association  with 
maldevelopment  or  arrested  descent  of  the  testis  (Fig.  455).  The 
following  are  the  varieties  most  commonly  met  with,  in  the  order  of 
frequency  : — 

1.  Patent  processus  vaginalis  in  scrotum,  with  lateral  diverticulum 

lying  between — 

(a)  Peritoneum  and  transversahs  fascia  (preperitoneal). 

(b)  Internal  oblique  muscle  and  external  oblique  aponeurosis. 

(c)  Transversalis  fascia  and  muscle. 

((/)  Peritoneum  and  iliacus  fascia  (retroperitoneal). 

2.  Processus  vaginalis  absent  from  scrotum  and  sac  found  lying 

between — 

(a)  External  oblique  aponeurosis  and  skin. 

(b)  Peritoneum  and  iliacus  fascia. 

Many  variations  of  the  above  may  be  met  with,  and  at  times  more 
than  one  diverticulum  may  be  present. 

It  is  quite  obvious  that  these  hernias  are  all  dependent  upon  some 
congenital  abnormality.  Their  chief  importance  lies  in  the  possibility 
of  the  lateral  sac  being  overlooked  in  the  performance  of  a  radical 
operation  ;  in  the  chance  of  reduction  being  effected  from  one  diver- 
ticulum into  another  ;  and  in  the  occurrence  of  strangulation  in  these 
diverticula.  The  intimate  union  of  the  transversalis  with  the  internal 
oblique  muscle  renders  the  occurrence  of  a  diverticulum  between 
these  muscles  very  rare,  although  such  cases  have  been  recorded. 
Interstitial  hernia  has  been  attributed  to  forcible  and  oft-repeated 
clumsy  efforts  at  reduction  ;  this  is  a  mistaken  theory.  Such  attempts 
could  only  lead,  where  no  diverticulum  is  present,  to  displacement 
of  the  whole  sac,  or  rupture  of  its  neck.  These  cases  come  under  the 
heading  of  ''Reduction  en  masse"  (p.  645),  and  are  not  true  inter- 
stitial hernias.  The  danger  of  strangulation  in  interstitial  hernias  is 
considerable,  and  only  occasionally  is  their  presence  diagnosed  before 
operation.  Some  bulging  of  the  abdominal  wall  above  and  outside 
the  internal  abdominal  ring  may  be  noticed,  or  it  may  be  possible 
to  feel  the  diverticulum  fill  up,  on  reduction  being  effected  from  the 
scrotum  ;  this  latter  being  then  kept  empty,  the  diverticulum  may 
be  detected  by  gurgling,  or  sudden  emptying,  on  reduction  of  its 
contents  being  effected. 

The  abnormalities  which  have  been  noted  in  association  with  these 
hernias  are — (1)  Retention,  maldevelopment,  and  ectopia  of  the  testis. 
(2)  Absence  of  the  cremaster  muscle.  (3)  Superimposition  of  the  abdo- 
minal rings.      (4)  Partial  obliteration  of  the  external  abdominal  ring. 


TRAUMATIC    INTERSTITIAL    IIKKNIA 


'.i  i 


Umbilical  hernia  is  bo  constantly  associated  with  diverticulation 
of  the  sac  thai  it  cannol  be  considered  .1-  an  irregular  hernia,  nor  ae 
interstitial,  although  the  diverticula  are  a1  times  found  both  between 
the  peritoneum  and  the  posterior  aheath  of  the  rectus  muscle,  and 
between  the  anterior  aheath  and  the  superficial  fascia. 

Traumatic  interstitial  hernia.— This  is  the  result  of 
ruptures  or  pathological 
lesions  <>i  1  he  abdominal 
wall  in  which  only  the 
deeper  layers  have  been 
affected  ;  it  is  conse- 
quently a  very  ran-  con- 
dition. It  has  been  aeen 
following  rupture  >>\  a 
Bection  of  the  rectus 
muscle.  Such  a  case  oc- 
curred in  my  nun  prac- 
tice ;  the  bowel  was 
found  between  1  he  muscle 
and  its  anterior  sheath, 
the  rupture  having  taken 
place  between  the  two 
lower  linese  transversa 
on  the  left  side.  Deep- 
seated  gummata  or 
chronic  abscesses  which 
have  resolved  under 
treatment  may  result  in 
the  formation  of  such  a 
hernia.  However  they 
are  produced,  they  can 
remain  interstitial  only 
for  a  time  ;  in  course  of 
years  the  coverings  be- 
come thinned  out,  fused 
together,  and  amalgam- 
ated with  the  .sac,  and  their  interstitial  character  is  thus  to  a  greal 
extent  lost. 

The  diagnosis  is  not  usually  difficult;  an  elastic,  hyper-resonant 
swelling,  exhibiting  intestinal  gurgling,  in  the  substance  of  the  ab- 
dominal wall  can  hardly  be  mistaken  for  anything  else  than  hernia. 
If  the  sac  contains  only  omentum  the  case  is  not  so  obvious,  for, 
impulse  being  probably  absent  owing  to  adhesions,  the  lobulation  and 
doughiness  of  the  mass  might  suggest  a  lipoma  or  other  form  of  tumour. 


Interstitial  hernia  and  retained 
testis. 
u  luthor  s  case.) 


6l2 


HERNIA 


Partial  enterocele  (Richter's  hernia). — Occasionally  a 
portion  only  of  the  lateral  wall  of  the  bowel  may  protrude  through  a 
hernial  ring,  or  through  some  adventitious  opening  (Fig.  456).  The 
ileum  is  the  part  most  commonly  affected,  and  though  the  site  of  the 
hernia  may  be  very  various,  the  condition  is  most  often  seen  at  the 
femoral  ring.  A  rare  form  of  hernia,  it  is  said  to  be  more  frequent  in 
women  than  in  men,  and  in  adults  than  in  children.  The  hernia  is 
always  small  in  size,  being  rarely  larger  than  a  marble,  and  the  ring, 
wherever  it  may  be,  is  always  narrow  ;  thus  strangulation  is  commonly 
the  first  evidence  of  the  trouble.     Its  chief  importance  lies  in  the  fact 

that  the  strangulation 
fails  to  give  rise  to  two 
of  its  cardinal  signs, 
viz.  complete  obstruc- 
tion and  faecal  vomit- 
ing. The  entire  lumen 
of  the  bowel  not  being 
involved  in  the  ring, 
flatus  and  faeces  may 
continue  to  pass  from 
time  to  time,  and  con- 
sequently faecal  vomit- 
ing may  be  absent. 
Therefore  gangrene  of 
the  constricted  portion 
may  easily  supervene 
before  a  diagnosis  is 
reached.  Reduction  is 
rarely  possible,  and 
even  when  it  is  accomplished  by  operation,  the  constricted  neck,  which 
is  on  the  antimesenteric  aspect  of  the  bowel,  may  be  permanently 
altered  by  the  development  of  cicatricial  tissue  in  its  wall,  with  the 
result  that  the  herniated  portion  remains  as  a  permanent  diverticulum. 
The  hernia  is  rarely  diagnosed ;  the  mortality  is  consequently 
high  (60-65  per  cent.),  even  when  operation  is  undertaken.  In  some 
cases,  however,  gangrene  has  supervened  and  a  spontaneous  recovery 
has  resulted,  leaving  the  patient  with  a  faecal  fistula  into  the  scrotum, 
or  at  the  groin  or  umbilicus, 

Hernia  of  Meckel's  diverticulum  (LittreV  hernia).— 
Although  only  dift'erin.o  from  the  last-mentioned  variety  in  its  embry- 
onic origin,  this  hernia  must  be  mentioned  separately,  since  the  lateral 
diverticulum  is  in  this  case  the  cause  of  the  hernia  and  not  the  result. 
Meckel's  diverticulum,  the  unobliterated  remains  of  the  vitello- 
intestinal  duct,  when  present,   springs  from  the  antimesenteric  aspect 


Fig.  456. — Richter's  hernia. 

{Fioni  Gould  and  Warren's  "  International  Text-Book 
of  Surgery.") 


s* 


HERNIA    WITHOUT  A   SAC 


613 


of  the  ileum,  usually  within  3  ft.  of  the  ileo-ciccal  valve,  and  ifi 
generally  attached  by  a  terminal  narrow  band  to  the  umbilical  site. 
Strictly  speaking,  therefore,  it  should  be  associated  with  umbilical 
hernia.  Since,  however,  it  may  be  found  in  the  sacs  of  other  hernias, 
it  is  given  a  special  place,  and  the  term  has  been  loosely  applied  to 
any  hernia  in  which  the  diverticulum  is  involved.  The  diverticulum 
varies  from  a  mere  prominence  on  the  surface  of  the  bowel  to  a  tube 
3  to  5  in.  in  length,  with,  at  times,  a  diameter  almost  as  great  as 
the  bowel  from  which  it  springs. 
Its  strangulation  therefore  pro- 
duces symptoms  and  results 
exactly  similar  to  those  of 
Hichter's  hernia,  with  the  ex- 
ception that  when  the  diverti- 
culum is  well  developed  the 
operative  treatment  is  simplified 
and  the  mortality  is  lessened. 

Hernia  in  the  absence 
of  a  sac.  —  Although  it  is 
hardly  accurate  to  say  that  a 
hernia  may  occur  without  a  sac, 
certain  protrusions  of  viscera 
do  occur  uncovered,  or  only 
partially  covered,  by  parietal 
peritoneum.  In  these  cases  a 
sac  either  has  disappeared  by 
an  alteration  in  the  position  of 
the  hernia,  or  can  be  found  lying 
to  one  side  of  the  main  mass  of  Fig.  457. — Extraperitoneal  hernia  of 
the  protrusion.     Such  instances  sigmoid, 

are  to  be  found  in  hernias  of  the 
caecum,  sigmoid,  and  bladder. 

Hernias  of  the  caecum  and  sigmoid  frequently  differ  in  no 
respect  from  other  inguinal  hernias,  and  these  organs  are  of  moderately 
common  occurrence  in  large  hernial  sacs.  But  at  times,  especially 
in  general  enteroptosis  (C41enard's  disease),  the  caecum  and  sigmoid 
descend  from  the  iliac  fossae  by  a  process  of  slipping  of  the  iliac 
peritoneum  (hernie  en  glissade),  leaving  the  abdomen  either  as  a 
direct  or,  much  less  commonly,  as  an  indirect  hernia.  At  first  a 
sac  is  present,  but  later,  as  the  hernia  enlarges,  the  peritoneum  of 
which  it  was  composed  assumes  a  more  and  more  anterior  position, 
the  bowel  coming  down  from  behind  it.  Ultimately  only  a  partial 
sac  is  to  be  found  in  front  and  high  up,  the  bowel  itself  forming 
the  posterior  and  inferior  wall  of  the  sac  (Fig.  457).     Some  of  these 


O.P.,  Pubes  ;  R.,  rectus  muscle;  r.R.,  peritoneal 
reflection  ;  S.',  sigmoid  colon  ;  s.",  scrotum. 


6i4  HERNIA 

cases,  supposed  to  be  congenital,  are  conjecturally  attributed  to 
overaction  of  the  gubernaculum  testis,  but  elongation  of  the  mesen- 
tery and  enteroptosis  furnishes  a  better  explanation. 

Hernia  of  the  bladder. — The  bladder  is  occasionally  met  with 
projecting  into  the  sacs  of  inguinal  or  femoral  hernias  ;  at  other  times 
it  is  seen,  especially  in  the  direct  form  of  inguinal  hernia  in  elderly 
subjects,  with  prostatic  obstruction  or  pulmonary  diatheses,  and  in 
the  perineal  and  pudendal  hernias,  presenting  as  a  bulging  fleshy 
mass  quite  uncovered  by  peritoneum.  In  such  cases  great  care  must 
be  exercised  not  to  mistake  it  for  a  thick-walled  sac.  The  presence 
of  loose  muscular  fibres  running  in  various  directions  and  of  large 
veins  on  its  surface  should  be  noticed,  and  any  doubt  as  to  its 
character  cleared  up  by  the  passage  of  a  rigid  bougie,  the  beak  of 
the  instrument  being  turned  into  the  protrusion.  The  nature  of  the 
hernia  may  be  suspected  when,  in  such  patients,  a  history  is  obtained 
of  the  swelling  being  more  marked  before,  and  less  prominent  after, 
micturition.  The  chief  characteristics  of  hernias  which  lack  a  peri- 
toneal sac  are  those  of  irreducibility  and  liability  to  incarceration; 
this  applies  especially  to  hernias  of  the  caecum  and  sigmoid. 

TREATMENT  OF  HERNIA  IN  GENERAL 

The  following  points  must  be  considered,  bearing  in  mind  that 
only  two  methods  are  available,  viz.  palliative  and  operative,  and 
that  only  the  latter  is  curative. 

Age.  Infancy.  —  Hernia  has  occasionally  been  cured  spon- 
taneously in  quite  young  children.  In  most  cases  it  is  not  cured,  for, 
although  apparently  so.  it  frequently  reappears  in  early  adult  life. 
The  difficulty  of  treating  young  children  by  palliative  means  is 
considerable,  for  the  following  reasons:  (1)  Their  restlessness  and 
irritability  and  constant  crying  tend  to  force  the  rings  open  and 
shift  the  truss.  (2)  Their  skins  are  tender,  and  in  the  poorer 
classes  are  easily  excoriated  by  the  accumulation  of  dirt  and  sweat 
beneath  the  truss.  (3)  Constant  increase  in  size  demands  a  relay  of 
fresh  trusses.  (4)  The  tissues  are  so  delicate  that  the  perpetual 
pressure  of  a  truss  probably  does  more  harm  than  good.  (5)  The 
ignorance  of  the  mothers  in  the  poorer  classes,  and  the  question  of 
expense,  resvdt  in  the  treatment  being  improperly  and  intermittently 
applied. 

The  objections  to  operation  during  infancy  are  the  possibibty  of 
spontaneous  cure,  the  delicacy  and  weakness  of  the  tissues,  and  the 
danger  of  fatality  or  of  sepsis. 

In  young  adults  a  hernia  can  only  be  cured  by  operation. 
The  surgeon's  decision  will  be  influenced  by  the  following  factors  : — 


PALLIATIVE   TRE  \T\ll  \  I  615 

1.  The  well-known  progressive  tendency  of  hernia. 

2.  The  influence  of  bard  manual  labour  on  the  one  hand,  and  of 
Bedentary  occupation  on  the  other;  both  of  which  conditions  favour 
the  growth  of  a  hernia. 

3.  The  constanl  danger  of  strangulation. 

I.  The  influence  now  exerted  by  the  Employers'  Liability  Act, 
which  makes  it  very  difficult  tor  any  man  who  is  ruptured  to  obtain 
employment. 

5.  The  greater  prospect  of  permanent  cure  the  earlier  the  operation 
i-  undertaken.  The  longer  the  hernia  has  been  in  existence  the  less 
this  prospeel  can  be  entertained,  a1  leasl  so  far  as  the  ordinary  methods 
of  operating  are  concerned. 

In  old  age. — At  the  age  of  50  and  over,  hernias  tend  to  become 
very  large  anil  the  tissues  much  degenerated,  and,  although  operation 
is  -till  capable  of  curing  many  of  these  patients,  the  risk  to  life  and 
the  difficulties  of  the  operation  are  greater,  while  the  ordinary  form 
of  operation  is  useless,  recurrence  being  the  general  rule.  In  such  cases 
the  use  of  my  double-filigree  operation  (p.  622)  is  strongly  advisable. 

PALLIATIVE    TREATMENT    OF   HERNIA 

This  consists  essentially  in  (a)  the  reduction  of  the  hernia,  and 
(b)  the  application  of  some  form  of  truss  to  prevent  its  re-descent. 

In  the  earlier  stages  of  hernia  the  saccular  content-  return  to  the 
abdomen,  by  their  own  weight,  on  the  patient  lying  down.  Later  on, 
for  reasons  already  given,  there  is  some  delay  in  the  process,  and  manual 
pressure  is  required  to  effect  the  reduction  ;  even  this  may  at  first 
fail,  and  the  return  may  only  be  accomplished  after  some  hours  of 
recumbency,  with  or  without  the  use  of  the  ice-bag  and  the  Trendelen- 
burg position,  both  of  which  tend  to  empty  the  vessels  of  the  omentum 
and  reduce  the  size  of  the  swelling. 

Reduction  by  manipulation. — The  patient  is  placed  in 
the  recumbent  position,  the  thighs  are  flexed  upon  the  abdomen  to 
relax  the  abdominal  muscles,  and,  in  the  case  of  inguinal  and  femoral 
hernia,  are  rotated  inwards  to  relax  the  fascia  of  the  thigh  and  the 
neck  of  the  sac.  The  latter  is  then  grasped  by  the  hand  in  such  a 
way  as  to  straighten  out  the  body  of  the  sac,  while  with  the  other 
hand  pressure  is  evenly  applied  to  the  fundus,  gently  but  firmly,  in  such 
a  maimer  as  to  favour  the  return  first  of  that  portion  of  the  content- 
occupying  the  neck,  following  which  the  contents  of  the  fundus  will 
usually  slip  back  easily.  In  the  case  of  omentum  alone,  the  sudden 
flaccidity  of  the  sac  will  indicate  the  completion  of  the  process,  while 
in  that  of  bowel  the  characteristic  gurgle  of  air  and  fluid  will  be  both 
felt  and  heard  at  the  moment  of  reduction. 

Gentleness  is  most  essential  in  these  manipulations,  since  roughness 


616  HERNIA 

or  clumsy  force,  if  the  hernia  is  difficult  of  reduction,  can  only  result 
in  pain  to  the  patient ;  in  bruising  and  inflammation  of  the  sac  and 
its  contents,  thus  producing  early  irreducibility  ;  and  possibly  even  in 
rupture  of  the  sac,  "  reduction  en  masse,"  and  strangulation.  On  no 
account  should  force  replace  patience  and  skill. 

At  times  a  hernia  may  be  irreducible  simply  from  the  fact  that  any 
attempt  at  reduction  is  resisted  by  the  patient,  owing  to  griping  pains, 
the  abdominal  muscles  being  involuntarily  contracted  at  each  attempt ; 
this  difficulty  may  be  overcome  by  making  the  patient  keep  the  mouth 
wide  open  and  instructing  him  to  breathe  deeply  and  not  to  hold  his 
breath.  This  failing,  a  general  anaesthetic  or,  preferably,  spinal 
analgesia  may  be  employed,  the  muscular  relaxation  provided  by  this 
latter  method  being  very  marked. 

The  direction  of  pressure  during  reduction  will  vary  with  the 
position  of  the  sac.  In  umbilical  hernia  it  should  be  directly  back- 
wards, but  these  hernias  are  so  commonly  irreducible  at  an  early  date 
that,  when  they  do  not  reduce  spontaneously,  little  success  is  to  be 
expected  from  manipulations.  The  direction  in  inguinal  hernia  should 
be  upwards  and  outwards  towards  the  iliac  spine.  In  femoral  hernia  it 
will  depend  much  on  the  direction  of  the  fundus  of  the  sac.  This 
reduction  is  always  more  difficult  to  effect  owing  to  the  tendency  of 
the  sac  to  turn  upwards  to  Poupart's  ligament,  the  narrowness  of 
the  canal,  and  the  sharp  edges  of  the  saphenous  opening  and  Gimbernat's 
ligament,  besides  which  the  sac  cannot  be  lifted  in  the  hand  as  in  the 
case  of  inguinal  hernia.  In  most  cases  the  pressure  must  be  in  a  down- 
ward and  inward  direction. 

The  dangers  of  using  undue  force  are  dealt  with  under  "  Reduction 
en  masse  "  (p.  645). 

Treatment  by  truss. — The  disadvantages  of  trusses  are  as 
follows  : — 

1.  They  do  not  cure  any  hernia  (a  very  small  proportion  in  quite 
yomig  infants  possibly  excepted). 

2.  They  are  inconvenient  and  often  uncomfortable. 

3.  They  are  costly  for  poor  patients,  who,  as  a  rule,  soon  wear 
them  out. 

4.  They  are  frequently  badly  fitted  or  not  fitted  at  all. 

5.  In  a  few  years  the  hernia,  growing  larger,  overcomes  the  truss. 

6.  Their  pressure  tends  to  thin  out  and  mat  together  the  under- 
lying tissues,  rendering  any  future  operation  much  more  difficult  and 
the  chances  of  cure  much  more  remote. 

7.  In  young  children  a  constant  change  of  truss  is  necessary, 
to  ensure  accuracy  of  fit  at  different  ages. 

8.  Although  useless  and  dangerous  in  irreducible  hernias,  they  are 
often  applied  to  these  by  ignorant  patients. 


PALLIATIVE   TREATMENT  617 

If  used,  the  truss  must  fulfil  the  following  conditions:  it  must  tit 
the  patienl  ;  be  neither  too  strong  nor  too  weak  in  the  spring;  be  of 
1  pattern  intended  for  the  variety  of  hernia  under  treatment;  and 
only  be  applied  in  the  recumbent  position  after  the  hernia  has  been 

rod  need 

For  ;i  description  of  the  numerous  forms  of  truss  the  reader  is 
referred  to   the  surgical    instrument-makers'   catalogues.     The   most 

popular  variety  is  the  circular  spring  truss:    a   modification  of  this 
with   a    prolonged  perineal  pad,  known   as  the    ''rat-tail    "  truss, 
sometimes    more    efficient   for   large    inguino-scrotal     hernias.      The 
"Moc-main"  truss  gives  more  with  the  movements  of  the  body3  but 

is  readily  damaged. 

For  inguinal  hernias  in  children  the  best  forms  are  the  india-rubber 
horseshoe-shaped  truss  and  the  woollen-skein  truss.  The  former  is 
the  better,  but  is  expensive,  for  new  ones  must  be  bought  as  the  child 
grows,  and  the  rubber  deteriorates  on  the  moist  skin  of  a  young  child 
and  may  cause  irritation.  The  skein  is  applied  as  follows  :  A  thick 
skein  of  undyed  berlin  wool  is  passed  round  the  waist  from  behind 
forwards  ;  the  end  on  the  side  of  the  hernia  is  threaded  through  its 
fellow  and  drawn  taut,  so  that  the  crossing  lies  immediately  over  the 
inguinal  canal.  With  the  child  in  the  recumbent  position  the  hernia 
is  reduced,  a  cotton-wool  pad  placed  beneath  the  crossing,  and  the 
free  end  of  the  skein  carried  back  through  the  perineum  and  fixed  to 
the  girdle  portion  just  to  the  outer  side  of  the  sacro-iliac  joint.  The 
skein  should  not  be  removed  in  the  bath,  but  replaced  by  a  dry  one 
afterwards. 

For  umbilical  hernia  in  an  infant  a  binder  over  a  pad  is  sufficient  ; 
no  pad  small  enough  to  enter  the  umbilical  ring  must  be  used.  Xothing 
is  better  than  a  leaden  disc  covered  with  lint  or  cotton-wool  and  sewn 
to  the  binder. 

Indications  for  use  of  a  truss. — Unless  there  is  some  definite 
contra-indication  to  operation,  the  surgeon  will  do  well  to  advise  a 
radical  cure  at  any  age.  Trusses  may,  however,  be  advisable  in 
infants  under  18  months  of  age,  in  patients  refusing  operation  or  out 
of  reach  of  surgical  assistance,  in  those  in  whom  any  surgical  inter- 
ference is  contra-indicated,  e.g.  in  the  victims  of  haemophilia,  diabetes, 
or  nephritis,  and  sometimes  in  very  old  people.  The  characters  of  a 
well- fit 'tin</  truss  should  be  as  follows  :  (1)  The  spring  should  lie  closely 
to  the  pelvis  without  undue  pressure  at  any  point.  (2)  It  should 
control  the  hernia  when  the  patient,  standing  with  legs  wide  apart 
and  thighs  everted,  and  stooping  so  as  to  rest  his  hands  on  his  knees, 
exerts  his  full  expiratory  force.  (3)  The  pad  should  be  soft  and  elastic, 
and  rather  flat.  (4)  The  pad  should  fall  not  on  the  external  abdominal 
ring,  but  on  the  whole  length  of  the  inguinal  canal. 


6iS  HERNIA 

OPERATIVE    TREATMENT 

The  principles  governing  a  true  radical  cure  are — (1)  complete 
removal  of  the  sac  ;  (2)  closure  of  the  hernial  aperture  ;  and  (3)  the 
production  of  an  unstretchable  cicatrix. 

In  some  cases  the  first  of  these  will  suffice,  but  in  most  cases  all 
three  are  required,  and  in  a  few  the  last  is  the  most  essential. 

Indications  for  operation. — Some  form  of  operation  is 
especially  indicated  in — (1)  patients  between  the  ages  of  18  months 
and  GH  years  ;  (2)  all  wage-earning  workmen  (in  view  of  the  Em- 
ployers' Liability  Act) ;  (3)  married  women,  or  women  about  to 
marry  ;  (4)  patients  going  out  of  reach  of  surgical  help  ;  (5)  where 
the  hernia  is  irreducible  ;  (6)  where  there  have  been  signs  of 
strangulation ;  (7)  where  there  is  a  gradual  increase  in  size ;  (8) 
where  the  hernia  is  associated  with  an  undescended  testis ;  (9)  where 
a  truss,  having  been  worn,  no  longer  controls  the  hernia. 

As  regards  contra-indications,  it  may  be  said  that  since  the  intro- 
duction of  filigree  implantation  these  have  been  greatly  reduced  in 
number.  It  is  open  to  question  whether  the  operation  is  desirable 
in  patients  over  the  age  of  65,  and  the  physical  condition  of  the  patient 
must  be  the  determining  factor  here.  In  hernias  of  such  gigantic 
size  that  the  return  of  the  abdominal  contents  presents  a  serious  risk 
of  paralytic  ileus,  operation  should  not  be  attempted  without  serious 
consideration.  In  cases  of  haemophilia,  diabetes,  albuminuria  of 
pathological  origin,  and  severe  ansemia,  operation  is  definitely  contra- 
indicated. 

Chief  factors  tending  to  a  successful  result. — 
Although  many  minor  points  must  be  considered,  the  success  of  a 
hernial  operation  largely  depends  on  observance  of  the  following 
conditions  : — 

1.  Complete  obliteration  of  the  sac  and  its  diverticula. 
— This  is  considered  by  some  surgeons  to  be  the  chief  essential  of  the 
operation,  and  in  quite  young  children  it  is  so  to  a  great  extent,  but 
it  cannot  be  admitted  in  the  case  of  adults.  In  them  the  long-con- 
tinued presence  of  the  hernial  contents  has  widened  and  stretched 
the  ring,  and  converted  much  of  the  sound  muscular  tissue  into  fibrous 
material.  Further,  the  presence  of  lateral  sacculi,  especially  in  femoral 
hernia,  must  be  remembered,  since,  if  overlooked,  the  reappearance  of 
the  hernia  may  be  accounted  as  a  recurrence  when  it  is  only  an  evidence 
of  faulty  technique. 

2.  Avoidance  of  tension  in  suturing. — Neglect  of  this  pre- 
caution will  result  in  the  rapid  cutting  out  of  the  deep  sutures,  the 
recession  of  the  muscles  covering  the  gap,  and  the  formation  of  an 
excess  of  fibrous  cicatrix. 

3.  Perfect  dryness  of  the  wound. — The  result  of  oozing  of 


OPERATIONS    FOR    INGUINAL    HERNIA  619 

blood,  serum,  and  liquid  fat  into  an  operation  wound  is,  in  the  first 
place,  to  furnish  a  nidus  for  bacterial  growth,  which  is  especially 
favoured  in  the  vicinity  of  I  he  groins  and  genitals  :  secondly,  il  separal 
the  Layers  of  the  abdominal  wall  near  the  wound;  and,  thirdly,  it 
increases  the  amount  of  fibrous  tissue  by  organization  of  the  exudate, 
and  thus  tends  ultimately  to  atrophy  of  the  muscular  layers  involved 
in  it. 

1.  Sufficiently  prolonged  convalescence. — Few  things  tend 
greatly  to  vitiate  the  result  of  hernial  operations  as  an  undue  cur- 
tailmenl  of  convalescence.  Young  cicatrices  are  easily  stretched 
long  after  the  occurrence  of  primary  onion.  The  present-day  custom 
of  discharging  hospital  patients  at  the  end  of  fourteen  to  twenty-one 
days  is  a  directly  predisposing  cause  of  recurrence. 

Opebative  Treatment  of  Inguinal  Hernia 
operation  may  be  divided  into  two  essential  parts,  viz.  (a)  the 
obliteration  of  the  sac,  and  (h)  the  closure  of  the  canal.  In  Bassini's 
operation,  the  one  usually  adopted,  the  sac  is  emptied  and  removed, 
the  open  neck  being  closed  either  by  transfixion  and  ligature  or,  if 
wide,  by  suturing;  this  method  secures  good  results  and  is  advised. 
Barker  recommended  ligature  and  removal  of  the  sac,  the  stump  being 
afterwards  carried  upwards  by  the  two  ends  of  the  ligature  passed 
through  the  abdominal  wall  and  tied  together  there.  Macewen  puck- 
ered up  the  sac  like  a  Venetian  blind  by  a  purse-string  suture  from 
below  upwards,  and  fixed  it  as  a  pad  over  the  internal  abdominal  ring. 
In  Rocker's  first  operation  the  fundus  was  passed  through  the  muscles 
above  the  internal  ring,  from  within  outwards,,  the  sac  drawn  after 
it  and  then  turned  downwards  and  fixed  to  the  anterior  surface  of 
the  external  oblique  aponeurosis.  Later,  Kocher  invaginated  the  sac 
into  the  abdomen  like  an  inverted  glove-finger,  and,  bringing  it  out 
through  peritoneum  and  muscles,  fixed  it  as  above. 

To  close  the  inguinal  canal,  two  methods  may  be  mentioned — 
(1)  Halsted's,  in  which  the  inguinal  canal  is  obliterated  by  suturing 
all  the  layers  of  the  abdominal  wall  behind  the  cord,  which  therefore 
is  made  to  run  Bubcutaneously  to  the  scrotum  ;  (2)  Bassini's,  in  which, 
after  removal  of  the  sac,  the  conjoint  tendon  is  stitched  to  Poupart's 
ligament  behind  the  cord,  and  the  gap  in  the  external  oblique  closed 
in  front  of  it,  so  as  to  maintain  the  valvular  action  of  the  canal. 

Choice  of  anaesthetic— The  best  results  are  obtained  with 
spinal  analgesia,  which  procures  a  maximum  of  muscular  relaxation, 
avoids  postoperative  vomiting,  and  minimizes  oozing  and  congestion. 
(See  Vol.  I.,  p.  688.) 

Bassini's  operation  (Fig.  458). — This  operation  may  be 
divided  into  three  stages — (1)  isolation,  ligature,  and  removal  of  the 


620 


HERNIA 


sac  ;    (2)  closure  of  the  inguinal  canal  ;    and  (3)  completion  of  the 
operation. 

1.  The  incision  extends  from  a  point  just  external  to  the  pubic 
spine  outwards,  parallel  to  and  slightly  above  Poupart's  ligament,  for 
a  distance  of  4  in.  or  more.  In  the  case  of  a  scrotal  hernia  it  may- 
be necessary  to  extend  it  downwards  over  the  outer  aspect  of  the 
scrotum,  but  this  should  be  avoided,  if  possible,  for  three  reasons  : 
firstly,  for  fear  of  sepsis  ;  secondly,  on  account  of  the  troublesome 
oozing  following  division  of  the  hernial  coverings  here;  and  thirdly, 
because  of  the  difficulty  of  bandaging  the  scrotum. 

The  aponeurosis    is  next  split  from  the  external  abdominal   ring 

outwards,  and  the  edges 
held  widely  apart  by  flat 
retractors — not  by  pressure 
forceps,  which  tend  to  tear 
the  edges  and  make  it 
difficult  to  cover  a  thick 
cord  or  implant  a  filigree. 
The  spermatic  cord  is  raised 
from  its  bed,  and  the  sac 
sought.  If  three  fingers  are 
passed  beneath  the  cord, 
and  the  coverings  are  di- 
vided in  its  length  by  a 
light  touch  of  the'  knife 
and  then  peeled  upwards 
and  downwards  with  the 
point  of  a  pair  of  dissect- 


Fig.  458. — Bassini's  method  of  closing 
inguinal  canal. 

(Fiom  "Annals  of  Surgery.") 


mg  forceps,  there  will  be  no  difficulty  in  recognizing  the  transverse 
white  fold  which  marks  the  fundus  of  the  sac. 

Then,  avoiding  injury  of  the  cord-like  vas,  the  sac  is  stripped 
from  the  surrounding  tissues  as  high  as  its  origin  from  the  parietal 
peritoneum,  and  the  fundus,  held  up  by  three  pairs  of  pressure 
forceps,  is  opened.  A  finger  is  introduced,  the  sac  is  explored, 
any  adherent  omentum  being  detached,  and  the  bowel  reduced ; 
lateral  sacculi  must  be  dissected  out  and  removed  with  the  sac.  The 
finger  being  still  kept  in  the  latter,  to  prevent  the  escape  of  con- 
tents, the  neck  is  transfixed  by  a  needle  carrying  a  ligature,  and  is 
firmly  tied  off  as  close  to  the  abdominal  wall  as  possible.  The  sac 
is  then  removed  at  a  short  distance  from  the  ligature. 

The  dangers  to  be  avoided  at  this  stage  are  as  follows :  (a) 
Puncture  of  the  bladder,  where  this  organ  lies  close  to  the  neck 
of  the  sac.  (b)  Transfixion  of  the  bowel  from  omitting  to  guard  it 
with   the  finger,     (c)  Tying-in  a  loop  of    bowel  or  piece  of  omentum 


It  ASS  I  NTS   OPERATION  621 

which    has    plot  railed    al    the    la>l     moment    <>n    removal    of   t  he  finger. 

((/)  Hipping  of  a  ligature  placed  upon  a  thick-walled  ami  vascular 
sao.  (- )  Tying-in  or  dividing  a  loop  of  the  vas  deferens  close  to 
the  deep  surface  of  the  neck  of  the  sac. 

2.  With  the  finger  or  the  candle  of  a  scalpel  the  peritoneum  is 

peeled  hack  from  the  deep  asped  of  Poupart's  ligamenl  BO  as  to 
display  its  shining  while  fibres,  and  the  conjoined  tendon  is  similarly 
peeled  back  from  the  overlying  aponeurosis  of  the  external  oblique 
as  far  as  possible.  At  this  point  the  ipiestion  will  arise  as  to  the 
necessity  of  reinforcing  the  inguinal  canal  by  the  method  described 
on  ]>.  622  :  where  the  patient  is  young,  the  musculature  good,  and 
the  hernia  not  of  unusual  size  nor  recurrent,  this  will  not  be  necessary. 
The  cord  is  held  out  of  the  way,  and  five  or  more  stout  chromicized, 
iodized  catgut  sutures  inserted  through  a  half-inch  grip  of  the 
conjoined  tendon  and  through  the  upturned  edge  of  Poupart's 
ligament,  from  the  pubic  spine  to  the  internal  abdominal  ring. 
The  woimd  is  flushed  out  with  normal  saline  and  thoroughly  dried, 
and  the  sutures  are  then  tied  just  sufficiently  tightly  to  approximate 
the  structures  included,  and  so  to  remake  the  posterior  wall  of  the 
inguinal  canal. 

Care  must  be  taken — (a)  to  avoid  puncturing  the  deep  epigastric 
vessels  ;  (b)  to  take  up  a  good  thickness  of  the  conjoined  tendon  in 
the  sutures  ;  (c)  not  to  tie  these  sutures  to  the  extent  of  strangula- 
tion ;  (d)  to  avoid  mattress-sutures,  which  of  necessity  cause  strangu- 
lation of  tissue  ;  (e)  to  take  up  only  the  deep  fibres  of  Poupart's 
ligament,  and  not  the  free  cut  edge  of  the  oblique  aponeurosis. 

3.  The  cord  is  replaced  in  position,  and  the  wound  in  the 
aponeurosis  closed,  the  edges  being  caught  up  in  the  manner  of  a 
Lembert's  suture,  which  prevents  the  tendency  to  split,  sufficient 
room  being  left  for  the  escape  of  the  cord  from  the  canal  without 
undue  constriction.  Finally,  in  stout  patients  the  superficial  fascia 
may  be  approximated  by  one  or  two  sutures  so  as  to  obliterate  any 
"  dead  space,"  and  the  skin  incision  is  closed  by  interrupted  silk- 
worm-gut sutures,  or  preferably  by  Michel's  clip-sutures.  The  dress- 
ings and  bandages  applied,  in  order  to  avoid  any  strain  being  brought 
upon  the  sutures  the  patient's  knee  and  hip  should  be  flexed  and  kept 
in  this  position  during  his  removal  to  bed,  when  at  some  distance 
from  the  scene  of  operation  ;  this  is  best  done  by  passing  a  figure- 
of-eight  bandage  round  the  leg  and  thigh,  and  fixing  the  limb  to  that 
of  the  sound  side  in  a  position  of  adduction  and  internal  rotation. 

Operative  Treatment  of  Large  Scrotal  Hernia 
Few  large   scrotal   hernias  can   be   cured    by   any  method  which 
relies    upon    the    patient's    tissues    alone.      The    musculature    is    no 


622 


IIKKNIA 


O 


I 


longer  firm  and  resilient,  and  frequently  the  inguinal  region  external 
to  the  internal  abdominal  ring  is- weak  and  bulging.     In  very  large 

scrotal  hernias  the  sac,  espe- 
cially  the  body  and  fundi] 
thick,  vascular,  and  adherent, 
and  1  he  attempt  to  strip  t  his 
<>ui  of  the  scrotum  results  in 
much  troublesome  oozing  of 
blood  and  tat.  which  not  only 
distends  the  cavity  of  the 
scrotum  but  also  invades  the 
layers  of  the  coverings  of  the 
sac,  making  it  impossible  to 
evacuate  the  clot.  It  is  thus 
often  unwise  to  attempt  the 
removal  of  such  a  sac  ;  it  is 
better  simply  to  detach  it  suffi- 
ciently at  the  neck  to  enable 
it  to  be  li gated  and  divided 
here  ;  thus  the  risk  of  a  scrotal 
hsematoma  is  avoided  at  the 
cost  of  a  comparatively  slight 
increase  in  the  size  of  the 
scrotum.  This  increase  may 
be  considerably  reduced  by  the 
use  of  a  large-sized  Keetley's 
suspender,  worn  for  some 
weeks  after  the  operation. 

If  the  scrotum  is  very  long 
and  flabby,  a  section  of  it  may 
be  removed,  but  no  attempt 
should  be  made  to  cut  away 
the  thick  coverings  of  the  sac, 
since  much  time  must  be  lust 
in  catching  and  tying  divided 
vessels. 

Double-filigree  opera- 
tion :  author's  method. 
Principles  involved.1 — "It 
was  with  the  idea  of  bringing 
all  eases  of  hernia,  especially 
of   recurrence,  within    the  scope  of 

the   Brit.    Med.    Journ.,  Aug.   14,   1909, 


Fig.  459. — Scrotal  hernia  with  vaginal 
hydrocele,  cured  by  filigree  im- 
plantation,    i .  tut/tor's  • 


those    of    meat    size    and  those 


1  This    passage    is    extracted    I 

where  fuller   details  will   be  found. 


DOUBLE-FILIGREE    OPER  VI  ION 


operative  treatment,  of  doing  away  entirely  with  the  truss,  and  of 
establishing  a  method  of  treatment  which  should  honestly  d> 
the  term  'radioal  cure,'  thai  I  devised,  in  L905,  the  method  which 
is  known  as  the  'double-filigree  method,9  and  which  has  been 
used  Bince  that  time  with  the  best  results.  The  principles  which 
underlie  it  are,  simply,  the  removal  of  the  Bac,  the  approximation  of 

onjoined  tendon  to  Poupart's  ligament,  and  the  rendering 
lutely  unstretchable  of  the  whole  operative  cicatrix  by  the  introduction 
of  a  scaffolding  of  silver  wire  known  .1-  'filigree.'  When  a  filigra 
of  silver  wire  such  as  will 
presently  be  described  is  in- 
troduced into  the  tissues 
of  the  inguinal  canal,  pre- 
suming that  it  is  perfectly 
aseptic,  the  firsl  efieel  is 
that  of  local  irritation  of 
the  parts  in  contact  with 
it  ;  this  results  in  the 
udation  of  lymph,  which 
rapidly  organizes  about  the 
filigree,  and  in  a  very  short 
time  new  vessels  and  young 
fibrous  tissue  are  produce  I. 
and  grow  around,  among, 
and  between  the  wires  of  the  filigree  to  such  an  extent  that  ere  long 
a  solid  plaque  is  formed  that  once  and  for  all  converts  the  inguinal 
canal  into  a  sound,  resistant  area  which  will  neither  stretch  nor 
bulge,  the  muscles,  peritoneum,  and  aponeurosis  being  welded  together 
by  the  filigree,  which  acts  much  as  the  backbone  of  a  sole  does  upon 
the  tissues  which  it  supports,  with  this  difference,  that  the  ends  of  the 
filigree  wires,  being  in  the  form  of  a  loop,  are  capable  of  act  in- 
as  retaining  sutures,  whereas  the  bones  of  the  sole  only  act  as  a 
scaffolding  for  support." 

Method  of  constructing  filigrees.— These  are  made  in  two 
tions  (Fiu.  460),  a  pubic  (a)  and  an  iliac  (b).  The  former 
measures  l|  in.  m  length  (the  normal  length  of  the  inguinal 
canal),  I  in.  in  width  at  the  narrow  end,  and  Hin.  at  the  wide 
end.  All  filigrees  being  constructed  on  the  principle  of  eight 
loops  to  the  inch,  there  will  be  thirteen  loops  on  either  side  of  the 
pubic  section. 

The  iliac  section  is  constructed  in  such  a  way  that  its  inner  third 
corresponds  in  shape  and  size  to  the  outer  two-thirds  of  the  pubic 
section.  Its  outer  end  must  met  the  requirements  of  the  case,  being 
trapezoid,  square,  or,  what  is  more  usual,  oblong,  and  of  a  total  length 


Fig.  -4G0. — Pubic  (a)  and  iliac  (b)  sections 
of  author's  filigree  for  inguinal  hernia. 
(c)  Midrib. 


624 


HERNIA 


of  2£  to  3  in.,  as  may  be  found  necessary.  The  wire  must  be  of 
unalloyed  Bilver,  and  of  the  same  gauge  for  all  filigrees,  viz.  No.  28 
standard  wire  gauge. 

A  board  "I  Bofl  wood  or  cork  is  taken,  and  on  it  is  placed  and  fixed 
by  pina  a  sheet  of  white  paper;  upon  this  the  plan  of  the  filigrees 
to  be  mad.'  is  drawn  out  accurately.  Stout  pins  are  then  inserted 
vertically,  as  in  Fig.  461.  and  an  odd  one,  the  "anchor"  pin 
(Fig.  461,  a),  is  placed  to  the  left  of  the  wider  end  of  the  plan  from 
which  To  start,  the  wire  being  given  a  turn  or  so  round  it.     The  wire 

now  runs  from  the 
end  pin  on  one  side 
to  the  second  from 
the  end  of  the  other, 
and  so  on  from  side 
to  side,  a  pin  being 
missed  each  time,  and 
the  wire  being  carried 
round  the  outer  side 
of  the  pins.  Having 
reached  the  last  pin 
on  one  side,  it  is  car- 
ried across  to  that  of 
the  other,  and  so  be- 
gins to  travel  back  to 
the  pin  from  which  it 
started,  when  the  an- 
chor pin  (a)  is  removed,  and  the  ends  of  the  wire  are  neatly  twisted 
together  roimd  the  outer  side  of  the  first  pin  of  the  row  and  cut  off 
short.  It  will  now  be  seen  that  the  crossing  of  the  wires  falls  evenly 
down  the  centre  of  the  filigree,  and  the  mid-rib  (Fig.  460,  c)  is  attached. 
Tins  is  done  by  taking  a  separate  short  strand  of  wire  and  fixing  it 
to  the  centre  of  the  strand  at  the  wide  end  ;  from  this  point  it  is 
carried  along  the  centre  of  the  filigree,  a  turn  being  made  round  each 
point  of  crossing  of  the  wires,  at  which  points  it  is  firmly  pinched 
by  a  pair  of  dissecting  forceps  to  fix  it  in  position.  On  reaching  the 
opposite  end  of  the  filigree  the  mid-rib  is  finished  off  by  being  attached 
to  the  last  strand  in  the  same  manner  as  that  by  which  it  was  fixed 
to  the  first.  The  surplus  being  cut  off  short  and  the  pins  removed, 
the  filigree  is  complete.  A  little  practice  is  required  to  produce  the 
most  perfect  work,  as  the  pull  of  the  wire  must  be  kept  equal  at  all 
points  and  breakages  avoided,  since  joins  are  not  only  clumsy  but 
difficult  to  effect. 

Method  of  implantation — The  filigrees  should  be  placed  in 
ether  for  five  minutes  to  remove  all  grease  from  them,  and  should  be 


461. — Method  of  constructing  author's 
filigree. 


DOUBLE-FILIGREE   OPERATION 


O25 


left  in  the  sterilizer  in  the  centre  of  the  most  actively  boiling  area  till 
the  moment  oi  implantation,  when  they  are  lifted  Btraight  from  the 
Bterilizei  into  the  wound. 

The  operation  is  al  firsl  conducted  exactly  as  in  performing  an 
ordinary  Bassini'a  closure,  excepl  that  the  aponeurosis  should  be  splil 
to  a  point  rather  farther  out,  and  the  peritoneum  mus1  be  more  freely 
separated  from  the  posterior  surface  of  the  conjoined  tendon,  as  must 
the  latter  be  from  the  aponeurosis  overlying  it.  From  this  point 
the  steps  are  ;l-  follows  :  The  >ae  having  been  isolated  and  dealt  with, 
tlu'  cord  is  held  out  of  the  way,  and  the  firsl  two  of  the  sutures  which 
are  to  approximate  the  conjoined 
tendon  to  Poupart's  ligament  are 
inserted,  and  their  ends  are  caught 
by  pressure  forceps.  These  sutures 
being  held  aside  by  the  assistant. 
the  pubic  section  of  the  filigree  is 
placed  upon  the  peritoneum,  its 
narrow  end  being  close  to  the  pubic 
spine,  and  its  wide  end  at  the  inner 
margin  of  the  internal  abdominal 
ring.  If  the  peritoneum  is  very 
loose  and  inclined  to  sag,  a  fine 
suture  may  be  used  to  unite  it  to 
the  filigree ;  as  a  rule,  however, 
this  is  unnecessary,  and  all  that  is 
required  is  to  bring  the  conjoined 
tendon  into  close  apposition  witli 
Poupart?s  ligament  over  the  filigree 
by  the  two  sutures  already  inserted, 
and  then  to  insert  as  many  more  as 
maybe  deemed  necessary,  care  being 
taken  to  keep  the  bed  in  which  it  lies  as  dry  as  possible.  In  cases  in 
which  the  muscular  wall  of  the  abdomen  external  to  the  internal  ring  is 
sound  and  strong,  the  cord  is  placed  in  position,  and  the  iliac  section  of 
the  filigree  is  taken  from  the  sterihzer  and  placed  beneath  the  aponeurosis 
in  such  a  way  that  its  inner  end  lies  over  the  internal  abdominal  ring  and 
upon  the  cord  for  a  space  of  f  in.,  the  outer  end  being  carried  outwards 
and  laid  upon  the  surface  of  the  internal  oblique  muscle,  one  or  two 
sutures  holding  it  in  place  (Fig.  462,  a).  If  the  above-mentioned  weak- 
ness is  present,  the  muscular  wall  is  divided  from  the  ring  outwards 
towards  the  iliac  spine  for  about  an  inch,  and  is  separated  from  the 
peritoneum  by  the  handle  of  a  scalpel ;  upon  this  peritoneum  the  outer 
end  of  the  iliac  section  is  laid,  being  lightly  sutured  in  place,  and  the 
muscles  are  brought  together  again  over  it  (Fig.  462,  b),  the  inner  end 


Fig.  462. — Positions  of  filigree 
sections  in  inguinal  canal. 

A,  In  ordinary  cases  ;  B,  where  there  is  exces- 
sive weakness  of  inguinal  region. 


626  HERNIA 

] vini  as  already  described.  Finally,  the  aponeurosis  is  sutured  in 
place,  and  the  wound  closed  by  means  of  Michel's  clips,  which  are 
removed  on  the  fifth  day. 

It  will  be  seen  that  the  cord  comes  to  be  "  sandwiched  "  between 
two  layers  of  filigree  in  the  canal,  the  natural  relations  of  which  are 
hardly  altered  ;  and  further  that  the  area  outside  the  internal  abdo- 
minal ring  is  fortified  by  a  filigree  which  may  be  made  of  any  size 
that  is  deemed  necessary. 

Granted  a  primary  union  of  the  wound,  the  hernial  gap  will  be 
found  to  become  as  impermeable  and  as  unstretchable  as  a  pad  of 
leather.  There  will  be  neither  pain  nor  discomfort  afterwards  ;  there 
is  not  the  least  fear  of  interference  with  the  cord  or  with  the  functions 
of  the  testis  ;  the  necessity  for  any  form  of  truss  is  done  away  with 
permanently,  and  the  operation  thus  offers  the  patient  a  radical  cure 
in  the  truest  sense  of  the  word. 

Operative  Treatment  of  Femoral  Herxia 

The  skin  incision  in  this  case  is  a  vertical  one  over  the  site  of  the 
saphenous  opening,  and  extends  from  h  in.  above  the  inner  point  of 
trisection  of  Poupart's  ligament  downwards  for  a  distance  of  4  in. 
A  network  of  veins  will  be  met  with,  formed  from  the  superficial 
epigastric  and  circumflex  iliac,  and  the  superficial  external  pudic 
vessels  ;./  these  must  be  divided  between  ligatures.  The  sac  will  usually 
be  found  without  difficulty,  lying  in  the  superficial  fascia  and  directed 
towards  the  centre  of  Poupart's  ligament,  the  neck  being  long  and 
narrow,  and  curving  round  the  falciform  process  of  the  fascia  lata 
to  reach  the  parietal  peritoneum. 

The  neck  should  be  entirely  freed  from  its  surroundings  as  high 
as  possible,  and  treated  exactly  as  described  under  inguinal  hernia, 
the  first  four  of  the  precautionary  points  there  mentioned  being  again 
borne  in  mind. 

The  necessity  of  using  some  means  for  closing  the  femoral  canal 
has  been  much  debated  by  surgeons,  and  the  following  methods  may 
be  mentioned  here  : — 

1.  Three  or  four  catgut  sutures  (not  mattress  sutures)  may  be 
passed  deeply  through  the  substance  of  the  pectineus  muscle,  and  then 
through  the  falciform  process  and  lower  edge  of  Pouparts  ligament, 
so  that,  when  tied,  these  Two  structures  are  closely  approximated, 
and  the  saphenous  opening  is  partially  obliterated.  This  method  does 
not.  however,  close  the  upper  end  of  the  femoral  canal,  and  involves 
the  exercise  of  considerable  tension  if  the  saphenous  opening  is  to  be 
even  narrowed  ;  for  this  reason  the  sutures  probably  cut  out  early 
and  do  more  harm  than  good. 

i'.  An  attempt  has  been  made  to  cover  the  gap  by  turning  up  a  flap 


OPERATIONS   FOR    FEMORAL    HERNIA 

(if  the  pectineua  muscle  and  Es^cia,  and  suturing  it  to  Poupart's  ligament, 
The  only  effect  oi  this  baa  been  to  damage  the  pectineus  muscle,  and, 
since  the  transplanted  flap  undergoes  fibroid  degeneration,  no  g 1 

results  from   it. 

3,  An  attempt  has  also  been  made  to  suture  Poupart's  ligament 
to  the  horizontal  ramus  of  the  pubes,  by  passing  deep  sutures  round 
the  ramus  or  t  brough  I  he  periosteum  covering  it. 

1.  With  a  similar  object  an  endeavour  has  been  made  to  unite 
these  two  structures  by  the  use  of  steel  staples  driven  through  the 
ligament  into  the  bone.  The  method  fails  owing  to  the  rarefying 
osteitis  which  shortly  loosens  the  grip  of  the  staples,  and  is  moreover 
dangerous,  since  the  points  of  the  loosened  staples  are  apt  to  wound 
the  bladder  and  femoral  vessels. 

5.  The  femoral  canal  has  been  plugged  with  decalcified  bone  or 
with  a  graft  of  bone  raised  from  the  ramus  of  the  pubes. 

6.  I  have  attempted  to  close  the  crural  ring  by  means  of  a 
"spider-web"  filigree  introduced  from  behind  Poupart's  ligament  (Fi?. 
465).  The  incision  was  made  above  and  parallel  to  the  ligament.  The 
operation  was  difficult,  and  it  is  as  yet  too  early  to  judge  of  its 
merits. 

These  operations  are  founded  on  an  erroneous  belief  that  femoral 
hernia  has  a  special  tendency  to  recur.  Such  recurrences  as  are  seen 
are  frequently  due,  as  Hamilton  Russell  has  pointed  out,  to  incom- 
plete removal  of  the  sac,  or  to  the  overlooking  of  lateral  diverticula, 
which  are  especially  common  in  this  form  of  hernia.  If  it  is  thought 
necessary,  owing  to  the  unusual  length  of  a  femoral  canal,  to  treat 
the  sac  in  any  special  way,  the  best  method  is  probably  that  of  Kocher, 
which  has  already  been  described. 

In  young  subjects  nothing  more  is  necessary  than  to  remove  the 
sac  completely  after  ligature,  and  close  the  wound  by  suture  or  clips  ; 
but  care  must  be  taken  to  leave  no  lateral  sacculus  overlooked. 

The  difficulty  of  closing  the  femoral  canal  is  an  anatomical  one. 
The  outer  wall  of  the  canal  being  formed  of  the  flaccid  femoral  vein, 
complete  closure  without  compression  or  obliteration  of  this  vein  is 
practically  impossible,  and  any  method  of  closing  the  saphenous 
opening,  whether  by  silver  filigree  or  simple  suture  of  its  margins, 
still  leaves  the  femoral  canal  unguarded,  and  causes  compression  of 
the  long  saphenous  vein. 

If  it  is  intended  to  utilize  the  first  method  of  narrowing  the  canal, 
care  must  be  taken  in  passing  the  sutures  to  guard  the  femoral  vein 
from  puncture  as  the  point  of  the  needle  passes  beneath  Poupart's 
ligament,  and  to  avoid  passing  the  point  so  deeply  that  the  peritoneum 
is  in  danger  of  being  wounded. 

In    some    cases,   especially  of    strangulated  femoral   hernia,   it  is 


62S  HERNIA 

advantageous  also  to  expose  the  neck  of  the  sac  from  above  Poupart's 
ligament,  so  gaining  access  to  the  entrance  to  the  canal. 

Operative  Treatment  of  Umbilical  Hernia 

The  points  to  be  aimed  at  are  complete  removal  of  the  sac  and 
the  closure  of  the  abdomen  in  separate  layers. 

The  incision  is  made  in  the  middle  line  of  the  abdomen  above  and 
below  the  hernia,  the  actual  prominence  being  enclosed  by  an  ellipse 
between  these  incisions.  Where  there  is  a  deep  layer  of  superficial 
fascia,  the  skin  incision  must  be  long  enough  to  give  free  access  to 
the  hernia.  The  abdomen  is  opened  above  the  level  of  the  hernia 
and  a  finger  is  introduced  to  search  for  adhesions.  These  are  separated, 
and  the  incision  is  then  carried  through  the  whole  thickness  of  the 
abdominal  wall  along  one  side  of  the  tumour,  and  the  sac  everted 
and  emptied  of  its  contents.  Any  degenerate  omentum  is  ligated 
and  removed,  care  being  taken  to  see  that  all  vessels  in  the  stump 
are  fully  secured.  The  sac,  including  its  cutaneous  covering,  is  then 
removed  close  to  the  neck  of  the  hernia.  If  the  gap  is  very  wide  it 
is  often  well  to  avoid  too  free  a  removal  of  the  peritoneal  sac,  lest 
difficulty  be  found  in  closing  the  abdomen  without  the  exercise  of 
tension.  The  bowels  are  now  retained  by  a  large  gauze  pad  placed 
within  the  abdomen,  and  the  peritoneum  is  closed  by  a  continuous 
suture,  the  pad  being  removed  before  closure.  The  margins  of  the 
rectus  sheath  are  laid  open  above  and  below  the  gap,  and  the  edges 
of  the  posterior  layers  approximated  like  those  of  the  peritoneum. 
The  rectus  muscles  are  brought  out  of  their  sheaths,  and  their  edges 
united  by  interrupted  sutures  which  should  include  a  considerable 
thickness  of  the  muscle  on  either  side,  -without  the  least  constriction. 
If  approximation  can  only  be  effected  by  the  exercise  of  tension,  either 
the  muscles  must  be  more  freely  brought  out,  or  the  case  must  be 
treated  by  filigree  implantation  (see  p.  629). 

In  freeing  the  muscles  it  is  necessary  to  detach  them  from  the 
linese  transversa?  which  bind  them  to  their  sheaths.  This  is  easily 
done,  but,  as  these  linese  transversa?  carry  large  vessels,  care  must  be 
taken  to  arrest  all  bleeding  before  proceeding  to  unite  the  muscles. 
Only  round-bodied  curved  needles  should  be  used  here,  since  bavonet- 
edged  or  Hagedonrs  needles  are  liable  to  divide  muscular  branches 
of  the  vessels,  and  so  give  rise  to  bleeding  and  cause  loss  of  time.  The 
anterior  layers  of  the  rectus  sheaths  are  now  united  by  a  continuous 
suture  ;  one  or  two  interrupted  sutures  are  inserted  to  hold  the  super- 
ficial fascia  together  and  obliterate  dead  spaces,  and  finally  the  skin 
incision  is  closed  by  Michel's  clips.  A  firm  binder  should  be  applied 
for  the  first  twenty-four  hours,  and  the  patient  should  be  placed  in 
the  semi-recumbent  position. 


OPERATIONS    FOR    UMBILICAL    HERNIA 

"Where  the  hernia  has  attained  to  rather  larger  dimensions,  various 
attempts  have  been  made  to  strengthen  the  abdominal  wall  by  the 
overlapping  of  its  aponeurosis;  bul  in  view  of  the  brilliant  results 
achieved  by  Bartlett's  method  (see  below),  and  of  i\\<-  greal  tendency 
of  all  umbilical  and  ventral  hernias  to  recur,  the  wisdom  of  these 
operations  is  doubtful,  since,  in  the  event  of  recurrence  after  their  per- 
formance, the  accomplishment  of  Bartlett's  method  is  rendered  much 
more  difficult.  The  best  of  these  overlapping  operations  is  that  of 
William  Mayo.  The  incisions  are  transverse  and  elliptical,  and  are 
carried  down  to  the  neck  of  the  sac,  after  which  the  aponeurotic  surfaces 
are  cleared  for  a  distance  around  this  point.  The  sac,  its  covin 
and  its  omental  contents,  are  removed  by  a  circular  incision  without 
dissection.  A  transverse  incision  is  made  through  the  abdominal 
aponeurosis  (posterior  rectus  sheath)  for  an  inch  or  less  on  either  side, 
and  the  peritoneum  is  separated  from  the  upper  of  the  two  flaps  thus 
made.  Sutures  are  now  passed  through  the  aponeurotic  layer  of 
the  upper  flap,  about  3  in.  from  its  free  margin  from  without 
inwards,  then  through  the  free  margin  of  the  lower  flap,  and  back 
again  through  the  upper  flap  from  within  outwards,  and  are  suffi- 
ciently drawn  upon  to  approximate  the  peritoneal  edges,  which  are 
closed  by  a  continuous  suture.  This  done,  the  sutures  are  so  tightened 
that  the  lower  aponeurotic  flap  is  drawn  into  the  space  between 
the  upper  flap  and  the  peritoneum,  where  it  is  fixed.  The  free  margin 
of  the  upper  flap  is  then  sutured  to  the  surface  of  the  aponeurosis 
below,  and  the  skin  incision  finally  closed. 

The  operation  is  not  suitable  for  very  large  hennas,  and  the 
separation  of  the  peritoneum  is  frequently  difficult  owing  to  old 
adhesions. 

Bartlett's  method  of  filigree  implantation :  author's 
modification. — For  hernias  which  have  grown  so  large  that  any 
prospect  of  cure  by  ordinary  means  is  out  of  the  question,  this 
method  is  the  only  one  which  can  be  relied  upon.  It  is  simple 
and  extremely  effective,  but  often  necessitates  a  very  extensive  and 
tedious  operation. 

The  filigree  which  I  use  (Fig.  463)  is  a  modification  of  Willard 
Bartlett's  original  pattern  in  that  it  is  barrel-shaped  in  outline,  and 
has  two  side  ribs  as  well  as  a  mid-rib.  It  is  made  in  precisely  the 
same  manner  as  the  filigrees  for  inguinal  hernia  (p.  624),  except  as 
regards  shape  and  size.  The  method  is  in  all  respects  that  of  Bartlett, 
except  that  the  filigree  is  implanted  between  the  rectus  muscle  and 
the  posterior  layer  of  its  sheath,  instead  of  upon  the  peritoneum. 

The  operation  is  conducted  in  precisely  the  same  manner  as  already 
detailed  for  small  hernias,  except  that  the  incision  must  be  very  much 
more  extensive,  often  indeed  from  the  ensiform  cartilage  to  the  pubes 


e>3o 


HERNIA 


(Fig.  452).  The  rectus  sheath  must  be  very  freely  opened  on  either 
side,  and  a  complete  separation  of  both  muscles  effected  from  both 
anterior  and  posterior  layers.  As  soon  as  the  edges  of  the  peri- 
toneum, together  with  those  of  the  posterior  layers,1  are  united,  all 
cozing  is  arrested,  and  the  edges  of  the  recti  muscles  being  widely 
retracted,  the  filigree  is  lifted  straight  from  the  sterilizer  and  at 
once  introduced  into  the  wound,  being  laid  upon  the  posterior  layer 
of   the  sheath    of    the   muscle.      There   is   no   need   to   suture   it   in 

place,  since,  being  of  the  exact  width 
of  the  sheath,  it  cannot  get  out  of  place. 
The  recti  muscles  are  now  approximated 
as  far  as  possible  over  it,  and  the  anterior 
layer  of  the  sheath  is  also  closed  by  a 
continuous  suture.  No  drainage  is  used, 
and  the  wound  is  closed  by  the  clips  from 
end  to  end. 

Before  operation  is  undertaken,  the 
size  of  the  filigree  to  be  used  must  be 
determined.  The  vertical  length  of  the 
hernial  gap  should  be  measured,  and  the 
filigree  made  at  least  one-third  longer  than 
this  measurement ;  the  width  remains 
constant — 4|  to  5  in. 

When  successfully  implanted,  these 
filigrees  do  away  entirely  with  the  neces- 
sity for  any  kind  of  belt  or  truss  after 
convalescence.  The  patient  may  wear  an 
abdominal  binder  for  a  month  from  the 
date  of  the  operation,  when  consolidation 
will  be  complete.  No  inconvenience  or 
discomfort  is  felt  subsequently,  nor  does 


Fig.  463. — Author's  modi- 
fication of  Bartlett's  ab- 
dominal filigree. 


the  method  interfere  with  pregnancy. 

Operative  Treatment  of  Ventral  Hernia 

What  has  been  said  of  umbilical  applies  equally  well  to  ventral 
hernia.  These  gaps  are  from  the  first  so  large  as  to  preclude  any 
operation  by  the  superimposition  of  flaps,  and  the  tendency  to  recur- 
rence is  so  great  that  only  a  few  are  cured  by  direct  approximation 
of  the  abdominal  wall  in  tiers.  It  is,  therefore,  best  to  treat  them 
by  filigree  implantation  from  the  first. 

Since  they  are  commonly  the  result  of  trauma  or  of  operative 
interference,   they  present   greater  difficulties   than   simple   umbilical 

1  Unless  these  are  taken  together  the  peritoneum  will  be  much  torn  by  the 
sutures. 


OPERATIONS  FOR  VENTRAL  HERNIA 


631 


hernias  owing  to  the  nature  of  the  cicatrix  and  adhesions;  this  is 
especially  bo  where  there  has  been  extensive  suppuration,  01  where 
abdominal  drainage  lias  been  employed. 

The  majority  are  Bituated  between  the  umbilicus  and  the  pubes 
(Kg.  I'll),  a  nt  1  consequently  there  is  a  deficiency  of  the  posterior  Bheath 
of  the  rectus  in  the  lower  half  of  this  area.  The  filigree  musl  there- 
fore lie  on  the  posterior  sheath  in  its  upper,  and  on  the  peritoneum  in 
its  lower  half,  and  should  come  well  down  below  the  crest  ol  1  lie  pnbes. 

Appendicular  and  other  lateral  hernias.— -Whenever 
drainage  of  an  appendicular  ab- 

--.  tir  reposition  after  (ileo- 
stomy or  colostomy,  lias  been 
performed,  a  ventral  hernia  is  to 
be  expected;  and,  owing  to  the 
disposition  of  the  muscular  layers 
here,  recurrence  is  almost  certain 
to  follow  any  attempt  to  cure 
such  a  hernia  by  simple  approxi- 
mation of  such  layers.  The 
situation  is  not  one  which  lends 
itself  to  the  application  of  belts 
or  trusses,  and  the  discomfort 
of  this  variety  of  hernia  is 
greater  in  proportion  than  that 
of  any  other  form  of  ventral 
hernia,  since  the  sac  always  con- 
tains the  caecum  and  ileo-csecal 
valve  or  the  sigmoid,  which  struc- 
tures are  usually  adherent  to  its  walls.  For  this  reason  also  much  of 
the  peritoneum  may  be  sacrificed  in  detaching  these  adhesions.  In 
a  case  of  mine1  it  was  impossible  to  close  the  gap  in  the  peritoneum, 
an  area  of  3  by  1|  in.  remaining  to  be  closed.  The  omentum  being 
too  short  to  suture  into  the  gap,  the  caecum  and  ileum  were  united 
together  and  sewn  to  the  edges  of  the  peritoneal  gap  in  order  that 
a  filigree  measuring  9  by  5  in.  might  be  implanted.  The  case  was 
successful,  and  the  patient  has  since  married  and  has  borne  a  child. 
The  filigree  in  such  cases  as  these  is  introduced  as  follows  : — 

The  skin  cicatrix  having  been  excised  by  an  elliptical  incision 
running  obliquely  from  the  loin  to  the  pubes,  the  abdomen  is  opened 
at  the  upper  end  and  the  adhesions  determined  as  above  detailed. 
The  peritoneum  is  separated  as  widely  as  possible  from  the  abdominal 
muscles  external  to  the  incision,  and  the  rectus  sheath  is  opened 
extensively  along  its  outer  edge.  The  muscle  is  then  freed  from  the 
»  Lancet,  Nov.  23,  1907. 


Fig.  404. — Ventral  hernia  following 
laparotomy,  cured  by  implanta- 
tion of  9-in.  filigree.  (Author's 
case.) 


632  HERNIA 

sheath  above  and  from  the  peritoneum  below  the  semilunar  fold  of 
Douglas.  When  the  oozing  is  arrested  and  the  edges  of  the  peri- 
toneum are  approximated,  the  filigree  is  introduced  so  that  its  inner 
loops  rest  on  the  posterior  sheath  of  the  rectus  muscle  above,  and  on 
the  peritoneum  below,  while  its  outer  loops  he  on  the  peritoneum 
only  and  are  deep  to  the  abdominal  muscles.  The  rectus  is  then 
brought  well  out  of  its  sheath  and  is  sutured  to  the  transversalis  and 
internal  oblique  muscles  over  the  filigree,  while  the  anterior  layer 
of  the  sheath  is  united  to  the  external  oblique  aponeurosis.  The 
skin  incision  is  finally  closed  in  the  usual  way. 

When  implanting  a  filigree  in  a  case  in  which  the  abscess  has  been 
drained  without  the  removal  of  the  appendix,  it  is  essential,  for  obvious 
reasons,  to  effect  this  removal  at  the  time  of  implantation.  Bartlett 
himself  goes  so  far  as  to  implant  a  filigree  in  cases  in  which  suppuration 
is  actually  present,  knowing  that  granulation  will  occur  through  the 
filigree ;  thus  he  avoids  a  second  operation.  To  this,  however,  I 
am  opposed,  for  the  following  reasons  : — 

1.  The  cases  in  which  an  appendix  can  be  safely  removed  from 
a  suppurating  cavity  are  comparatively  few. 

2.  The  implantation  requires  the  more  extensive  opening  up  of 
muscular  layers,  involving  a  fresh  area  of  infection. 

3.  Cases  are  at  times  seen  of  secondary  sinuses  after  the  removal 
of  a  gangrenous  appendix,  owing  either  to  the  infection  of  the  ligature 
of  the  stump,  or  to  the  presence  of  small  portions  of  concretion  over- 
looked at  the  operation. 

4.  The  presence  of  a  filigree  in  a  suppurating  area  renders  the 
process  of  healing  much  more  prolonged. 

5.  There  is  always  the  chance  of  damage  occurring  to  the  filigree, 
or  of  its  becoming  displaced  in  the  repeated  dressings  necessary 
during  healing. 

6.  In  the  process  of  healing,  the  filigree  is  apt  to  be  pushed  out 
by  the  granulations  to  a  more  superficial  position  than  that  which  it 
should  properly  occupy. 

It  is  better  surgery  to  allow  the  cavity  to  close,  and  then  at  a 
subsequent  date  to  implant  a  filigree  under  aseptic  conditions. 

Operative  Treatment  of  Lumbar  Herxia 

When  occurring  at  Petit's  triangle,  hernia  may  often  be  cured  by 
simple  approximation  of  the  muscles  ;  but  if  the  gap  be  wide,  it  must 
also  be  submitted  to  filigree  implantation.  When  the  hernia  appears 
in  the  upper  region  of  the  loin  this  is  the  only  sound  method  of  treat- 
ment, especially  when  it  is  the  result  of  an  operation  on  the  kidney. 
Here  the  muscles  have  been  divided  transversely,  much  of  their  nerve 
supply  has  been  damaged,  and  extensive  fibrosis  and  atrophy  have 


OPERATIONS    FOR    HERNIA  633 

occurred.  The  filigree  may  I"-  placed  upon  or  deep  to  the  transverealis 
fa-.-i.i .  the  lattei  being  the  simpler  method.  The  operation  is  by  no 
means  bo  simple  ;is  in  the  case  «>f  the  abd en,  owing  to  the  narrow- 
ness .uid  depth  of  the  costo-iliac  space  and  the  unyielding  nature  of 
the  fascia.  The  filigree  should  measure  aboul  1  to  5  in.  in  length 
and  3  to  4  in.  in  width,  and  should  be  of  the  same  shape  as  the 
abdominal   filigree. 

Operative  Treatment  of  ({luteal  and  S<  latic  IIi;i:ma 
These  hernias  may  occasionally  be  operated  upon  when  not  stran- 


Fig.  465. — Author's  spider-web  filigree  for  use  in  perineal 
and  femoral  hernia. 

gulated.  The  incision  and  dissection  are  in  all  respects  the  same  as 
for  ligature  of  the  respective  arteries,  the  essential  point  being  to 
obtain  very  free  access  to  the  parts.  The  difficulties  are  chiefly  those 
of  depth,  the  presence  of  the  network  of  vessels,  and  the  difficulty  of 
effecting  reduction.  In  dividing  the  constriction,  care  must  be  taken 
of  the  vessels  and  nerves  in  the  vicinity,  and,  as  these  are  numerous 
and  their  courses  not  always  regular,  it  is  wiser  to  depend  on  clear 
exposure  of  the  parts  than  to  be  guided  by  any  anatomical  rule.  In 
case  of  failure,  abdominal  section  should  be  performed  as  for  obturator 
hernia  (see  p.  650). 


634  HERNIA 

Operative  Treatment  of  Perineal  Hernia 

The  majority  of  perineal  hernias  should  be  attacked  by  the  com- 
bined  abdominoperineal  route.  They  are  extremely  difficult  to  deal 
with,  and  so  variable  in  their  character  that  no  definite  rule  can  be 
laid  down  for  their  operative  treatment.  The  difficulties  to  be  over- 
come are  the  reposition  and  retention  in  place  of  the  pelvic  organs, 
especially  the  bladder,  which  at  times  occupies  the  sac  ;  and  the 
depth  of  the  hernial  ring  both  from  within  and  from  without.  The 
Trendelenburg  position  is,  of  course,  essential,  and  there  are  no  sound 
structures  to  assist  in  closing  the  tra  j>.  My  spider-web  filigree  (Fig.  465) 
may  be  used,  being  implanted  either  beneath  the  peritoneum  from 
within,  or  beneath  the  levator  ani  muscle  from  without,  as  may  be 
found  easiest.  In  either  case  it  should  He  between  the  peritoneum 
and  the  muscle,  the  sac  having  been  invaginated  and  tied  off  within 
the  abdomen.  In  women  this  may  necessitate  the  separation  of  the 
broad  ligament  from  the  pelvic  floor,  but  that  is  of  httle  consequence, 
since  it  can  easily  be  sutured  in  place  again.  Where  the  hernia  is 
found  to  contain  the  ovary,  broad  ligament,  uterus,  and  bladder,  it 
will  be  advisable  to  complete  the  operation  by  performing  a  ventro- 
fixation of  the  uterus,  and  possibly  removal  of  the  ovary  and  tube 
of  the  affected  side  at  the  same  time. 

The  greatest  care  must  be  taken  to  ascertain  the  presence  or  absence 
of  the  bladder  in  these  cases,  since  any  injury  to  it  in  so  deep  a  wound 
is  difficult  to  repair.  On  one  occasion  a  pudendal  hernia  appearing 
in  the  labium  majus  was  mistaken  for  a  vaginal  polypus,  and,  being 
ligatured  and  removed,  was  found  to  contain  a  length  of  intestine 
and  a  mass  of  omentum  (Graser,  see  Bibliography). 

POSTOPERATIVE    COMPLICATIONS    OF   HERNIA 

These  fortunately  are  few.     The  following  have  been  noted  : — 

1.  Chronic  pain  and  hyperaesthesia  of  the  cicatrix. 

— This  is  probably  due  to  the  inclusion  of  some  of  the  cutaneous 
nerves  in  the  ligatures  and  sutures.  If  severe  and  genuine  (many 
of  these  patients  are  malingerers  or  neurotic  youths),  the  cicatrix 
mav  be  undercut  with  a  tenotomy  knife  where  the  condition  is 
one  of  hyperesthesia  ;  but  where  chronic  pain  is  complained  of  it 
is  better  to  open  up  the  old  wound  down  to  the  aponeurosis,  or  even 
to  the  conjoined  tendon,  and  divide  high  up  any  nerves  found  in 
the  course  of  dissection.  Where  pain  is  complained  of  only  in  wet  or 
cold  weather,  the  condition  is  not  to  be  benefited  by  operation. 

2.  Formation  of  a  haematoma. — This  may  occur  in  the 
course  of  the  inguinal  canal  or  in  the  scrotum.  It  is  not  uncommon 
after  extensive  stripping  away  of  large  adherent  sacs  in  scrotal  hernias. 


POSTOPERATIVE   COMPLICATIONS  635 

Unless  very  extensive  or  causing  a  distinct  rise  of  temperature,  these 
hematomas  should  aol  be  opened,  especially  when  in  the  scrotum; 
it  1-  almosl  impossible  to  evacuate  all  the  clol  from  this  region,  since, 
besides  occupying  I  he  cavity  of  I  be  scrotum,  it  lias  extensively  invaded 
the  layers  of  the  hernial  coverings,  from  which  it  cannol  be  dislodged. 
It  1-  better  to  use  the  ice-bag  Eor  the  firsl  twenty-four  hours,  and  hoi 
fomentations  or  simply  pressure  after  this.  Unless  very  large,  these 
swellings  nearly  always  subside  in  time.  When  suppuration  occurs  they 
musl  be  freely  opened,  bu1  in  such  cases  the  hernia  commonly  recurs. 

."..  Atrophy  of  the  testis.-  This  is  due  either  to  (a)  dai 
to  the  vas  deferens  by  cutting  or  crushing  ;  (l>)  damage  to  the  spermatic 
artery  :   or  (c)  compression  of  the  spermatic  cord  by  too  tighl  suturing 
of  the  canal.     When  atrophy  is  established  there  is  no  remedy. 

4.  Formation  of  a  varicocele. — This  is  also  due  to  tighl 
suturing,  and  is.  indeed,  often  a  3tage  in  the  previous  condition.  When 
Buturing  is  complete,  the  external  abdominal  ring  should  with  difficulty 
admit  the  tip  of  the  little  finger. 

5.  Torsion  of  the  testis.— As  the  result  of  twisting  the 
organ  round  in  the  process  of  removing  a  patent  processus  vaginalis, 
especially  in  cases  of  retained  testis,  this  accident  may  occur,  the 
testis  being  finally  left  in  the  scrotum  with  the  digital  fossa,  as  it  should 
be,  on  the  outside,  but  with  a  complete  twist  of  the  cord  above  it. 
Such  an  accident  may  give  rise  to  pain,  swelling  of  the  scrotum,  vomit- 
ing, distension  of  the  abdomen,  and  constipation  ;  the  case  may  thus 
resemble  one  of  intestinal  obstruction.  The  accident  can  only  be  the 
outcome  of  carelessness. 

6.  Persistent  vomiting.— The  importance  of  this  lies  in  its 
effect  on  the  result  of  the  operation.  Its  cause  may  be  (a)  the 
anaesthetic  ;  (b)  intestinal  obstruction ;  (c)  torsion  of  the  testis ; 
(d)  general  peritonitis  ;  or  (e)  paralytic  ileus. 

The  danger  of  forcible  and  prolonged  vomiting  is  that  it  strains 
or  ruptures  the  sutures,  tears  the  conjoined  tendon,  stretches  the 
young  cicatrix  of  the  union,  and  causes  fresh  oozing  into  the  tissues, 
all  of  which  effects  tend  to  produce  recurrence.  Since  the  introduction 
of  spinal  analgesia  into  my  practice  there  has  been  only  one  case  of 
prolonged  vomiting  (viz.  five  hours)  ;  this  was  in  a  woman,  and  was 
not  violent.  The  use  of  spinal  analgesia  is  a  strong  factor  in 
prevention  of  recurrence. 

7.  Intestinal  obstruction. — This  may  result  from  the  tying- 
in  of  a  loop  of  bowel  in  the  neck  of  the  sac,  or  from  the  production 
of  a  volvulus,  or  the  forcing  of  a  loop  of  bowel  through  a  rent  in  the 
omentum  or  mesentery  by  a  rough  attempt  to  return  large  masses 
of  hernial  contents.  The  prophylaxis  is  obvious  ;  the  treatment, 
immediate  laparotomy. 


636  HERNIA 

8.  Faecal  or  urinary  fistulse. — These  are  the  outcome  of 
direct  injury  to  the  bowel  or  bladder,  from  transfixion  by  sutures 
or  inclusion  in  ligatures  ;  or,  in  the  case  of  the  bowel,  they  are  due 
to  subsequent  sloughing  at  the  site  of  constriction  when  a  strangulated 
loop  has  been  released  and  returned  to  the  abdomen. 

Either  of  these  conditions  may  improve  spontaneously  after  a 
time,  or  may  require  an  operation  to  effect  a  cure.  In  the  case  of 
the  bladder,  a  catheter  should  be  tied  in  and  the  cavity  washed  out 
twice  a  day  without  forcible  distension  ;  the  patient  should  be  given 
such  drugs  as  urotropine  in  10-gr.  doses  ;  acid  sodium  phosphate 
3ss,  salol  10  gr.,  etc.,  in  such  vehicles  as  infusion  of  buchu,  pareira, 
barley-water,  etc. 

When  the  bowel  has  been  damaged,  much  will  depend  on  the  level 
of  the  injury.  If  it  be  in  the  upper  regions  of  the  jejunum,  emaciation 
will  ensue  rapidly  ;  whereas  fistula  of  the  colon  produces  little  change 
in  the  nutrition. 

9.  Suppuration. — Owing  to  the  situation  of  inguinal  and  femoral 
operations,  asepsis  is  more  difficult  to  ensure  than  in  the  case  of  ventral 
or  umbilical  hernia.  But  in  all  cases  the  greatest  care  must  be  taken 
to  avoid  infection  of  the  wound,  since  suppuration  is  almost  certain 
to  be  followed  by  recurrence.  Absorbent  and  unabsorbable  sutures 
like  silk  and  linen  thread  should  be  avoided,  since  they  often  give 
rise  to  sinuses  of  prolonged  duration.  The  safest  material  is  probably 
catgut  soaked  in  ether  and  then  treated  by  Moskowitz's  iodine  method, 
or  some  of  the  specially  prepared  brands  in  sealed  tubes  ;  these  latter 
are,  however,  very  costly.  Where  deep  suppuration  occurs,  nothing  is 
gained  by  waiting  except  where  a  filigree  has  been  implanted  ;  the 
wound  should  be  reopened,  all  sutures  removed,  the  wound  swabbed 
out  with  pure  carbolic  or  lysol,  and  lightly  packed  with  gauze.  After 
healing,  any  recurrence  must  be  treated  by  filigree  implantation. 

Suppuration  following  filigree  implantation. — In  the  case  of 
inguinal  hernia  it  is  wiser  not  to  remove  the  filigree  at  once — many 
cases  heal  soundly  with  constant  washing  out ;  but  there  is  certainly 
a  tendency  for  the  iliac  section  to  shift  its  position  upwards,  when 
the  hernia  may  recur  beneath  it.  In  such  a  case  I  have  been  able 
successfully  to  close  the  gap  by  the  implantation  of  a  fresh  iliac  section 
after  the  wound  had  healed,  without  removing  that  which  had  shifted. 

In  the  case  of  umbilical  and  ventral  filigrees  there  is  little  chance 
of  displacement,  since  they  are  held  in  position  by  the  outer  margins 
of  the  rectus  sheath.  Thorough  syringing  of  the  wound,  which  should 
be  opened  at  the  lower  end,  will  overcome  the  difficulty,  peroxide 
of  hydrogen  being  used  in  a  5-to-8- volume  solution.  The  ultimate 
result  is  simply  to  render  the  abdominal  wall  firmer  than  ever,  owing 
to  the  greater  amount  of  cicatricial  tissue  produced  around  the  filigree. 


POSTOPERATIVE   COMPLICATIONS  637 

should  be  taken  not  to  disturb  the  wires  of  the  filigree  by  I 
introduction  of  probes,  etc.,  for  the  presence  of  Loose  wires  in  the  sinus 
is  the  Buresl  means  of  preventing  healing. 

li».  Retention  of  urine. — In  all  operations  on  the  -_rr<»ins 
or  perineum  this  is  liable  to  occur  from  time  to  time  ;  it  would  appear 
to  be  Less  frequent  where  the  operation  is  performed  under  spinal 
analgesia.  In  any  case,  it  1-  a  temporary  complication  of  no  great 
importance,  and  is  readily  overcome  by  the  use  of  a  catheter. 

11.  Orchitis  and  epididymitis. — This  is  Been  in  a  cei 
proportion  of  inguinal  hernias.  Jr  usually  comes  on  within  the  first 
four  or  rive  days  after  operation,  and  may  last  for  a  week  or  ten  days, 
gradually  subsiding  on  the  application  of  hot  fomentations,  or  the 
use  of  glycerine  and  belladonna  ;  the  patient's  bowels  should  be  kept 
freely  open,  and  the  testes  should  be  kept  raised  upon  a  pad  of  soft 
wool  supported  on  a  band  of  strapping  passed  across  the  thighs.  The 
prognosis  is  good,  suppuration  being  rare,  and  little  damage  resulting 
to  the  testes.  The  trouble  is  probably  due  to  rough  handling  of  the 
vas  and  to  congestion  of  the  pampiniform  plexus  of  veins. 

12.  Paralytic  ileus. — Tins  is  by  far  the  most  serious  com- 
plication of  hernial  operations,  and  is  rarely  met  with  except  in  the 
case  of  prolonged  manipulation  of  the  bowels  in  dealing  with  unusually 
large  hernias,  especially  umbilical  ones  in  plethoric  subjects.  The 
symptoms  are  those  of  gradually  oncoming  intestinal  obstruction,  and 
unless  the  bowels  can  be  induced  to  move,  the  case  is  likely  to  terminate 
rapidlv.  If  distension  occurs  and  cannot  be  relieved  by  the  rectal 
tube  and  turpentine  enemata,  time  should  not  be  wasted  in  the  ad- 
ministration of  drugs,  but  the  abdomen  should  be  opened  and  the 
caecum  or  distal  end  of  the  ileum  brought  out  of  the  wound,  and  a 
Paul's  tube  inserted,  after  which  strychnine,  sulphate  of  magnesium, 
croton  oil,  etc.,  may  be  given.  Eserine  salicylate  and  pituitrin  are 
also  of  value,  and  may  be  given  hypodermically.  Where  vomiting 
has  actually  set  in,  the  prognosis  is  very  grave  ;  and  where  the  vomit 
is  faecal  the  case  is,  as  a  rule,  hopeless. 

In  extreme  cases,  where  the  manipulation  gives  reason  to  fear 
the  possibility  of  ileus,  prevention  is  better  than  cure,  and  the  caecum 
Bhould  be  opened  at  the  time  of  operation,  a  Paul's  tube  being 
inserted  and  the  bowels  evacuated  at  once.1  Such  drastic  treatment 
must,  of  course,  be  reserved  for  the  most  exceptional  cases. 

Recurrence  of  hernia  after  operation. — Although  less 
commonly  seen  than  formerly,  recurrence  is  still  far  from  rare,  and 
may  be  met  with  as  the  result  of — 

1.  Suppuration,  which  accounts  for  about  60  per  cent,  of  all  cases. 

1  On  this  subject  the  reader  is  referred  to  a  valuable  article  by  Victor  Bonney 
(see  Bibliography). 


638  HERNIA 

2.  Badly  chosen  cases  and  unsuitable  methods.  Thus,  even 
Bassini's  method  is  incapable  of  dealing  with  large  hernias,  especially 
in  men  over  40.  and  in  the  presence  of  atrophied  abdominal  walls. 
Operations  done  under  general  anaesthesia  on  patients  the  subjects 
of  asthma  or  bronchitis  are  likely  to  result  in  failure.  Simple  approxi- 
mation of  the  abdominal  layers  in  umbilical  or  ventral  hernias  of  any 
size  is  generally  quite  useless. 

3.  Tightly  tied  sutures — especially  if  "  mattress  sutures  "  are  used, 
since  strangulation  of  the  tissues  is  produced  and  the  sutures  cut  out 
too  soon.  The  forcible  dragging  down  of  the  conjoined  tendon  is  apt 
to  produce  a  separation  of  the  muscular  fibres  above  the  level  of  the 
inguinal  canal.  The  practice  of  dragging  up  the  neck  of  the  sac  by 
sutures  passed  through  the  abdominal  wall  and  then  tied  produces 
a  cicatrix  and  therefore  a  weak  spot  in  the  muscle,  and  this  may 
easily  be  the  starting  point  of  a  recurrence.  In  my  opinion  the 
practice  is  unsound  and  should  be  abandoned. 

■i.  Unduly  short  convalescence  :  this  should  never  be  less  than 
three  weeks  in  bed,  and  one  week  on  a  couch  or  chair. 

5.  Postoperative  vomiting  :  this  is  best  avoided  by  the  use  of  sj)inal 
analgesia. 

6.  The  overlooking  of  lateral  sacculi  in  a  hernia  :  this,  however, 
is  rather  a  failure  to  cure  than  a  recurrence. 

7.  Omission  to  relax  the  tension  on  the  sutures  after  operation, 
by  flexion  of  the  knee  and  hip. 

B.  Constipation,  which  induces  straining,  especially  when  the  patient 
has  to  use  a  bed-pan.  The  bowels  should  be  kept  loose  and  the  semi- 
recumbent   (Fowler)  position  permitted  during  the  act. 

9.  Distension  due  to  flatulence  :  this  applies  especially  to  abdo- 
minal hernia. 

10.  Allowing  the  patient  to  come  round  from  the  anaesthetic  before 
application  of  the  bandages.  A  sudden  spasm  of  vomiting  is  often 
enough  to  rupture  the  deep  sutures  and  undo  the  whole  of  the  work. 

After-treatment  of  hernial  operations. — Finn  bandag- 
ing should  be  the  rule  after  operation,  a  soft,  thick  pad  of  wool 
being  placed  over  the  part  to  prevent  any  oozing.  On  his  return 
to  bed  the  patient's  hips  and  knees  should  be  semiflexed,  and  kept 
in  this  position  by  means  of  a  rest  or  pillow  for  a  period  of  a  fortnight 
in  cases  of  inguinal  and  femoral  hernia  when  any  plastic  closure  has 
been  attempted. 

For  some  time  after  the  bandases  are  discarded,  while  the  cicatrix 
is  still  young,  the  rings  should  be  supported  by  the  pressure  of  the 
hand  during  defrecation,  coughing,  or  other  expulsive  effort.  On 
no  account  should  any  form   of  truss  be  applied. 

In  young  children,  care  must  be  taken  to  prevent  the  soiling  of  the 


\l  TKR-TRKATMKNT 


639 


dressings  with  urine  or  faeces,  l>y  Erequenl  inspection  oi  the  bandages 
and  immediate  redressing  where  necessary.  With  very  young  and 
restless  children  it  may  even  he  ailvisal)le  t<>  apply  some  form  oi 
retentive  apparatus,  such  as  a  vertical  suspension  as  for  fractured 
femur,  <>r  a  Thomas's  hip  splinl  slightly  benl  to  a  suitable  shape  and 
fixed  by  plaster  bandages. 

Elderly  subjects  should  be  treated  either  with  abed-resl  or  a  double 
inclined  plane,  the  latter  being  very  much  the  better  (Fig.  4G6).  In 
tins  position  the  flatulent  distension  often  occurring  after  operations 
on  umbilical  and  ventral  hernias  is  more  easily  dealt  with.  The  treat- 
ment may  be  assisted  by  the  retention  in  situ  of  the  rectal  tube,  and 
the  administration  of  enemata  of  turpentine,  asafcetida,  etc.,  and  of 


Fig.  466. — Double  inclined  plane  (Fowler's  position). 

(From  "Annals  of  Surgery  ") 

carminatives  by  the  mouth.  Calomel  given  in  grain  doses  every  hour 
up  to  5-8  gr.,  or  tincture  of  mix  vomica  n\vi-x  every  three  hours, 
will  often  help  where  there  is  no  vomiting. 

Unless  the  patient  complains  of  discomfort,  the  binder  applied 
after  operation  should  not  be  loosened  for  twenty-four  hours ;  a 
tight  binder  is  a  great  safeguard  to  the  sutures  after  a  general 
anaesthetic,  but  it  may  be  a  source  of  danger  to  the  patient's  respira- 
tion if  distension  is  marked. 


STRANGULATED   HERNIA 

Strangulation — that  is.  the  constriction  of  a  viscus,  usually  the  bowel, 
in  such  a  manner  as  to  cause  arrest  of  its  circulation  as  well  as  of  its 
natural  function — is  one  of  the  commonest  of  surgical  emergencies. 
It  may  occur  at  any  time  in  the  life-history  of  a  hernia,  and  is  not 
infrequently  the  first  evidence  of  the  presence  of  hernia.  It  is  met  with 
in  all  the  forms  of  hernia  already  mentioned,  as  well  as  in  certain  others 


640  HERNIA 

known  as  "  internal  hernias,"  since  they  are  confined  to  the  abdominal 
cavity ;  in  these  latter  strangulation  is  the  rule,  and  they  are  rarely 
seen  except  in  this  condition. 

The  effects  of  strangulation  vary  according  to  the  age  and  condition 
of  the  patient,  the  portion  of  the  bowel  involved,  and  the  tightness 
of  the  constriction.  Thus,  although  if  unrelieved,  either  spontaneously 
or  by  operation,  the  inevitable  result  is  death,  this  result  is  much 
more  rapid  when  the  patient  is  old  and  feeble  or  excessively  plethoric, 
and  the  constriction  tight  and  high  up  in  the  intestinal  canal.  In  such 
cases  the  fatal  result  may  ensue  in  the  course  of  three  or  four  days, 
whereas  in  less  unfavourable  cases  seven  to  ten  days  may  elapse.  The 
cause  of  death  is  commonly  exhaustion,  peritonitis,  or  septic  pneumonia. 

Cardinal  symptoms  of  strangulation. — These  are  essen- 
tially those  of  intestinal  obstruction,  viz.  (1)  vomiting ;  (2)  absolute 
constipation  both  as  to  flatus  and  faeces  ;  (3)  gradual  distension  of 
the  abdomen ;  and  (4)  the  appearance  of  an  irreducible  swelling  in  the 
neighbourhood  of  one  or  other  of  the  hernial  sites. 

1.  Vomiting. — At  first  this  maybe  mere  effortless  regurgitation  of 
the  gastric  contents,  preceded  by  a  sense  of  overfullness  of  the  stomach, 
possibly  in  spite  of  the  fact  that  no  food  has  been  taken.  In  the  course 
of  a  few  hours  the  vomiting  becomes  worse  and  is  accompanied  by  active 
retching,  bitter  greenish-yellow  bile-stained  fluid  being  ejected  in 
mouthfuls.  As  time  goes  on,  the  vomiting  progresses,  undiminished 
by  drugs,  and  large  quantities  of  foul-smelling  brown  liquid  are  brought 
up,  having  a  distinctly  feculent  odour.  Ultimately,  if  the  condition 
is  unrelieved  and  the  patient  lives  sufficiently  long,  the  actual  contents 
of  the  large  bowel  may  be  vomited  ;   this,  however,  is  rare. 

2.  Constipation. — This  may  not  at  first  be  complete,  some  of  the 
contents  of  the  rectum  below  the  constriction  being  voided  ;  but  it 
very  soon  becomes  absolute,  neither  faeces  nor  flatus  passing  the  anus. 
An  occasional  exception  to  this  is  met  with  in  the  case  of  Richter's 
hernia  (p.  612),  especially  when  low  down  in  the  ileum,  slight  action 
of  the  bowels  and  little  vomiting  being  present  throughout.  The 
diagnosis  is  thus  rendered  very  difficult. 

3.  Distension  of  the  abdomen. — When  increasing  rapidly,  and 
especially  when  supervening  on  rigidity  of  the  parietes,  this  is  a  sign 
of  great  importance.  It  may  be  due  to  gas  within  the  bowel  or  free 
in  the  peritoneal  cavity.  The  diagnosis  is  not  always  easy.  Stress 
is  laid  by  some  writers  on  the  absence  of  liver  dullness,  but  the  sign  is 
very  deceptive,  the  bowel  at  times  being  able  to  insinuate  itself  between 
the  liver  and  the  abdominal  wall,  thus  giving  rise  to  the  belief  that 
there  is  free  gas  in  the  peritoneal  cavity.  However,  taken  in  conjunc- 
tion with  other  signs  of  abdominal  disaster,  such  as  sweating,  collapse, 
rapid  pulse,  and  marked  abdominal  facies,  it  is  -of  value.     The  rapidity 


STRANGULATED    HERNIA  641 

of  the  onset  of  distension  must  be  considered  in  the  diagnosis  of  its 
cause.  Thus  a  gradual,  slow  development  is  the  rule  in  strangulation, 
whereas  rapid  and  acute  increase  suggests  perforation  of  the  bowel. 

Distension  may  occur  even  when  omentum  only  is  strangulated, 
the  paralysis  which  originates  it  being  due  to  reflex  inhibition  of  the 
splanchnic  nerves. 

4.  Appearance  of  a  swelling, — The  above  signs,  in  association 
with  a  swelling  at  the  umbilicus,  groin,  saphenous  opening,  or  other 
hernial  site  (especially  when  the  swelling  is  irreducible  or  has  recently 
become  so,  is  tender  on  manipulation,  and  transmits  no  expansile 
impulse  on  coughing),  presents  a  picture  the  significance  of  which 
should  be  obvious.  The  swelhng  is  always  tender,  and  the  pain  is 
referred  to  the  umbilical  region. 

For  the  rest,  the  condition  of  the  patient  is  as  follows  :  The  tongue 
is  thickly  coated,  at  first  with  dirty  white  fur,  later  becoming  dry  and 
brown,  and  sordes  form  on  the  lips.  The  patient's  face  assumes  the 
sunken,  anxious  appearance  known  as  "  facies  Hippocratica,"  his 
voice  becomes  feeble  and  conversation  is  carried  on  in  whispered  gasps, 
articulation  being  indistinct  owing  to  dryness  of  the  tongue.  The 
breath  becomes  horribly  foul,  the  pulse  rapid  and  running,  the  tem- 
perature often  subnormal ;  gradually  exhaustion  sets  in,  and  the  patient 
dies  in  a  comatose,  asthenic  condition.  At  times  death  is  due  to 
inhalation  of  fseculent  vomit  and  subsequent  gangrene  of  the  lung 
or  septic  pneumonia ;  or,  the  bowel  becoming  gangrenous,  general 
septic  peritonitis  terminates  the  case. 

Varieties  of  strangulated  hernia. — All  the  forms  of 
hernia  may  undergo  strangulation,  but  that  most  frequently  affected 
in  proportion  is  the  femoral  variety,  although  inguinal  strangulation 
is  the  more  often  met  with.  Umbilical  is  less  frequent,  but  more 
serious,  since  it  occurs  in  obese  and  elderly  women  of  plethoric  habit. 
Ventral  hernia  rarely  becomes  strangulated,  owing  to  the  wide  neck  of 
the  sac  ;  whereas  obturator,  sciatic,  and  gluteal  hernias  are  rarely  seen 
except  in  the  condition  of  strangulation,  which  generally  occurs  on 
their  first  appearance. 

Retrograde  strangu  lation. — This  is  a  rare  variety,  first  described 
by  Maydl,  in  which  the  contents  of  the  sac  remain  normal,  but  in 
which  a  part  of  such  contents  having  retraced  its  steps  and  passed 
into  the  abdomen  again,  becomes  there  strangulated.  It  has  been 
described  affecting  bowel,  omentum,  the  appendix,  and  Fallopian 
tube.     (Sultan,  see  Bibliography). 

Causes  of  strangulation. — A  hernia  which  has  been 
spontaneously  reducible  for  years  may  become  strangulated  as  the 
result  of — 

1.  Some  excessive  exertion,  such  as  the  lifting  of  a  heavy 

-V 


642  HERNIA 

weight,  defecation,  vomiting,  coughing,  etc.,  the  immediate  effect  being 
the  forcing  of  a  fresh  mass  of  omentum  or  a  coil  of  bowel  into  the 
sac,  the  neck  of  which  is  too  narrow  for  it ;  or  the  production  of  a 
volvulus  of  bowel  already  in  the  sac. 

2.  Some  violence  applied  from  without,  such  as  foolhardy 
and  clumsy  attempts  at  the  reduction  of  an  irreducible  hernia  ;  the 
result  being  its  conversion  into  one  of  the  forms  of  "reduction  en 
masse/'  the  setting  up  of  an  inflammatory  oedema  of  the  sac  or  its 
contents  ;   or  the  forcing  of  the  bowel  through  a  rent  in  the  omentum. 

3.  Simple  rapid  increase,  from  overgrowth  of  fat,  of  the 
omental  contents  of  the  sac. 

4.  Sudden  distension  of  the  bowel  in  the  sac  from  acute 
enteritis. 

5.  Gradual  increase  in  the  bulk  of  an  incarcerating  mass  in  the 
bowel. 

6.  The  growth  of  a  tumour  in  the  sac. 

Of  the  above  causes,  the  first  is  by  far  the  commonest. 

Pathology  of  strangulation.  —  The  process  may  be 
divided  into  three  stages,  between  which  there  is  no  real  dividing  line, 
but  which  are  easily  recognizable  at  operation  and  are  important  as 
a  guide  to  treatment  and  prognosis.  The  first  stage  is  that  of  con- 
gestion from  venous  engorgement,  the  bowel  being  cyanosed  and  the 
omentum  dark  and  covered  by  large  loops  of  over-filled  veins.  As 
the  result  of  this,  oedema  of  the  contents  shortly  occurs,  and  the  pressure 
within  the  sac  is  increased.  Soon  the  engorgement  becomes  so  great 
that  fluid  accumulates  in  the  sac,  and  this  is  frequently  turbid  or 
blood-stained.  The  sac  is  now  tense,  and  the  bowel  becomes  deep- 
purple  in  colour,  and  blood  may  be  effused  into  its  lumen. 

The  second  stage  is  marked  by  the  loss  by  the  bowel  of  its  smooth, 
glistening  appearance,  by  its  blackish-grey  colour,  and  by  its  wet-wash- 
leather  consistence.  The  fluid  now  becomes  distinctly  feculent  in 
odour. 

The  third  stage  is  that  of  actual  gangrene  of  the  bowel,  or  of 
ulceration  and  perforation  at  the  site  of  constriction. 

In  the  case  of  Richter's  hernia,  where  only  the  lateral  wall  of  the 
bowel  is  involved,  it  is  clear  that  perforation  may  take  place  without 
the  signs  already  described  as  characterizing  strangulation  being 
present. 

Results  of  untreated  strangulation. — The  prognosis  is 
usually  fatal ;  at  times,  however,  recovery  takes  place  as  the  result 
of  the  formation  of  a  fsecal  fistula  on  the  surface  of  the  body. 

Strangulated  inguinal  hernia. — Inguinal  hernia  becomes 
strangulated  more  frequently  in  males  than  in  females,  owing  prob- 
ably to  the  nature  of  their  work  ;    the  immediate  cause  is  usually 


STRANGULATED    III-. KM  \  643 

thf  desoanl  of  a  fresh  mass  of  omentum,  and  it  is  more  commonly  the 
latter  which  is  Btrangolated.  The  constricting  agent  is  to  be  found 
either  in  the  rigid  pillars  of  the  external  abdominal  ring,  01  in  the 
fibrous  band  which  commonly  surrounds  the  neck  *  * t"  the  Bac.  Only 
occasionally  is  the  hernia  Btrangulated  on  its  first  appearance.  Owing 
to  the  wider  nature  <>f  the  ring  and  canal  hen-,  the  symptoms  take 
rather  longer  to  establish  themselves  than  in  the  case  <>f  femoral  hernia. 

These  hernias  are  usually  scrotal,  and  on  examination  the  scrotum 
will  be  found  to  be  distended,  hard,  tender,  dull  to  percussion,  or, 
when  bowel  is  present,  with  resonance  diminished  owing  to  the 
presence  of  fluid  in  the  sac.  No  expansile  impulse  is  felt  on  making 
the  patient  cough.  Any  attempt  at  reduction  is  resisted  owing  to 
the  pain,  and  the  patient  lies  with  the  thigh  of  the  affected  side  drawn 
up  and  inverted  in  an  endeavour  to  relax  the  tension.  In  many  cases 
there  is  rigidity  of  the  abdominal  muscles  on  the  affected  side,  and 
retention  of  urine  is  not  uncommon.  Pain  may  be  complained  of  in 
the  testis  and  loin  owing  to  pressure  on  the  constituents  of  the 
cord,  and  in  time  cramping  pain  referred  to  the  umbilicus  is  felt.  In 
the  case  of  women,  the  ovary  may  be  contained  in  the  sac,  in  which 
case  pain  is  referred  to  the  "  bottom  of  the  back  "  (sacralgia)  as  well 
as  to  the  umbilicus,  and  may  be  aggravated  by  raising  the  cervix 
uteri  per  vaginam.  The  appendix  in  a  strangulated  hernia  gives  rise 
to  no  sign  by  which  its  presence  can  be  recognized. 

Strangulated  femoral  hernia.  —  As  compared  with 
inguinal,  this  strangulation  is  more  serious  in  that  (1)  being  less  out- 
wardly obvious,  it  is  more  liable  to  be  overlooked  ;  (2)  being  trans- 
mitted through  a  narrower  canal,  it  is  more  acute  in  its  onset ;  and 
(3)  with  the  sharp  edge  of  Gimbernat's  ligament  always  in  close 
contact  with  it,  ulceration  is  more  prone  to  occur  early. 

It  is  seen  especially  in  women  (since  in  them  femoral  hernia  is 
commoner)  at  all  ages,  but  chiefly  between  the  ages  of  30  and  50. 
The  tumour  produced  is  usually  quite  a  small  one,  and  if  of  recent 
occurrence  may  easily  be  mistaken  for  an  enlarged  gland  ;  there  is, 
however,  no  periglandular  thickening,  in  spite  of  the  tenderness,  the 
mass  is  spherical  rather  than  lobulated,  and  not  adherent  to  the  skin, 
and  unless  the  sac  is  inflamed  there  is  no  redness  over  it,  such  as  usually 
denotes  femoral  adenitis. 

The  cause  of  strangulation  is  similar  to  that  in  inguinal  hernia,  but 
the  constricting  agent  is  always  the  knife-edge  of  Gimbernat's  ligament. 
This  structure  is  so  prominent  that  reduction,  either  spontaneous  or 
intentional,  is  almost  impossible,  and  is  seldom  seen.  For  this  reason, 
too,  any  prolonged  effort  at  taxis  is  more  dangerous  than  in  inguinal 
hernia  ;  "  reduction  en  masse "  is  less,  while  rupture  of  the  bowel 
is  more  likely  to  occur  as  a  result. 


644  HERNIA 

Strangulated  umbilical  hernia. — This  condition  is  almost 
confined  to  women  of  the  age  of  40  to  60,  especially  those  who 
are  markedly  obese,  of  plethoric  habit,  and  frequently  the  subjects 
of  chronic  asthma  and  bronchitis.  For  these  reasons  umbilical 
strangulation  is  very  dangerous,  and  its  mortality  high.  Reduction 
can  very  rarely  be  effected  owing  to  the  size  of  the  mass,  its 
omental  adhesions,  the  tightness  of  the  constriction,  and  the 
numerous  lateral  sacculi  present.  The  constricting  agent  is  in  this 
case  the  neck  of  the  sac  itself,  and  this  is  often  of  almost  cartilaginous 
consistence.  The  especially  dangerous  nature  of  the  strangulation 
is  further  due  to  the  following  factors  : — 

1.  The  depth  and  extent  of  the  wound  necessary  for  its  relief. 

2.  The  jejunum  as  well  as  the  transverse  colon  and  omentum  being 
at  times  involved,  the  shock  is  proportionately  greater  than  when  the 
lower  end  of  the  ileum  is  in  question. 

3.  The  size  of  the  mass  to  be  exposed  and  returned  ;  many  feet 
of  bowel  being  frequently  involved. 

4.  The  fact  that  such  patients  are  bad  subjects  for  any  kind  of 
operation,  more  especially  those  which  involve  resection,  anastomosis, 
or  drainage  of  the  intestine. 

5.  If  jejunostomy  is  required,  rapid  emaciation  is  likely  to  result. 

6.  The  amount  of  handling  necessary  to  replace  these  large  hernias 
in  an  abdomen  already  full  of  tensely  distended  bowel  frequently  leads 
to  the  occurrence  of  paralytic  ileus. 

Case  for  case,  strangulated  umbilical  hernia  is  attended  by  a  worse 
prognosis  than  any  other  form  of  external  strangulation,  and  therefore 
admits  of  less  delay  in  its  relief  ;  next  to  it  comes  femoral,  and  lastly 
inguinal  strangulation. 

TREATMENT  OF  STRANGULATED  HERNIA 

The  only  sound  and  safe  method  when  strangulation  of  any  variety 
of  hernia  has  been  diagnosed  is  immediate  operation. 

Employment  of  taxis. — When  a  case  of  apparent  strangu- 
lation comes  under  consideration,  the  question  will  arise  as  to  the 
justifiability  of  taxis  for  its  reduction.  In  only  a  few  cases,  however, 
is  it  possible,  and  in  fewer  still  is  it  safe  ;  it  should  only  be  used  as  a 
last  resource,  as  where  a  patient  obstinately  refuses  any  operation. 
If  it  can  ever  be  said  to  be  justified,  it  can  only  be  where  the  trouble 
is  of  but  a  few  hours'  duration  ;  in  a  hernia  hitherto  easily  reducible  ; 
where  there  is  absence  of  pain  and  tenderness  ;  and  even  then  it 
should  be  of  the  gentlest  kind,  and  should  neither  be  prolonged  nor 
repeated. 

Dangers  of  forcible  taxis. — 1.  "  Reduction  en  masse  "  (Figs.  467 
to  474).     The  following   remarks  apply  especially  to  inguinal  hernia. 


TAXIS   IN   STRANGULATED    HERNIA  645 

When  a   hernia  which  is  irreducible  or  strangulated  1-  subjected 

to  forcible  manipulation  with  a  view  to  its  reduction,  certain  displace- 
ments of  the  sac  or  of  its  contents  may  result ;  these  displacements, 
known  as  "reduction  en  masse,"  may  be  thus  enumerated: — 

(1)  The  whole  sac  with  its  unreduced  contents  may  be  displaced 
upwards — (i)  subcutaneously  between  the  skin  and  the  abdominal 
wall ;  (ii)  interstitially  between  the  internal  and  external  oblique  muscles 
(Fig.  467),  or  between  the  trans versalis  muscle  and  the  peritoneum 
(preperitoneal)  (Fig.  468)  ;  (iii)  behind  the  iliac  peritoneum,  caecum, 
or  sigmoid  (retroperitoneal). 

(2)  The  sac  may  be  ruptured  circularly  at  the  neck  and  the  contents 
forced  into  any  of  the  above  positions,  the  body  and  fundus  remaining 
behind  (Fig.  469). 

(3)  The  sac  may  be  ruptured  laterally  and  the  contents  forced 
through  the  rent  either  interstitially  as  above,  or  simply  into  the 
scrotum  (Fig.  470). 

(4)  The  contents  may  be  forced  from  the  main  sac  to  a  lateral 
diverticulum  (Fig.  471). 

(5)  The  contents  may  be  forced  through  a  rent  in  the  omentum 
and  the  whole  reduced  into  the  abdomen,  the  sac  remaining  behind 
(Fig.  472). 

(6)  The  bowel  may  be  reduced  across  an  adhesion  at  the  neck  of 
the  sac  (Fig.  474). 

2.  The  bowel  may  be  torn  across  at  the  neck  of  the  sac  (Fig.  473), 
general  peritonitis  rapidly  terminating  the  case. 

3.  Short  of  rupture,  serious  haemorrhage  may  be  produced  in  the 
sac  ;  or  such  bruising  may  take  place  that  gangrene  rapidly  supervenes. 

"  Reduction  en  masse  "  is  thus  a  very  serious  condition,  since  it 
suggests  for  the  moment  that  reduction  has  been  correctly  performed, 
although  an  irreducible  hernia  may  have  been  converted  into  a  strangu- 
lated one,  while  a  strangulated  hernia  may  be  allowed  to  persist.  When 
suspected,  the  only  possible  treatment  is  immediate  laparotomy.  The 
possibility  of  the  occurrence  of  "  reduction  en  masse "  should  be 
thought  of  where  a  very  sudden  reduction  effected  under  considerable 
pressure  is  accompanied  by  sharp  pain,  and  is  followed  by  persistence 
of  the  signs  of  strangulation,  or  by  those  of  general  peritonitis.  The 
mortality  of  operation  in  such  cases  is,  of  course,  very  high. 

In  very  early  cases  it  may  be  possible  to  assist  taxis  by  placing 
the  patient  in  the  Trendelenburg  position,  and  applying  an  ice-bag 
for  some  time  before  the  attempt  is  made ;  or  by  the  use  of  ether 
applied  drop  by  drop  to  the  swelling.  These  methods  may  reduce 
the  volume  of  gases  in  the  intestine  and  diminish  the  congestion  to 
some  extent,  but  on  the  other  hand  there  is  the  danger  of  producing 
thrombosis  in  the  constricted  vessels.     In  any  case,  time  is  thus  lost. 


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648  HERNIA 

A  better  method  is  to  submit  the  patient  to  spinal  analgesia,  or  to 
chloroform  anaesthesia,  proceeding  at  once  to  operation  if  taxis  fails. 

Operative  Treatment  of  Strangulated  Hernia 

Precautions. — The  following  precautions  must  be  observed 
prior  to  operation  : — 

1.  The  preliminary  cleansing  is  best  done  by  swabbing  with 
acetone,  followed  by  painting  with  iodine  (see  Vol.  I.,  p.  266),  without 
the  previous  use  of  soap  and  water. 

2.  In  every  case  where  possible  the  patient's  stomach  should  be 
washed  out.  This  is  especially  necessary  where  a  general  anaesthetic 
is  to  be  employed,  the  danger  of  inhalation  of  faeculent  vomit  being 
considerable.  Septic  pneumonia  following,  or  even  asphxyia  during 
operation  may  be  the  result  of  neglecting  this  precaution.  In  any 
case  the  material,  if  retained  in  the  stomach,  is  highly  toxic. 

3.  Every  precaution  must  be  taken  against  shock,  which  is  often 
marked  in  these  cases.  Extract  of  pituitary  gland  (pituitrin)  may 
be  given  hypodermically  an  hour  before  operation  or  on  the  table ; 
while  during  the  operation  two  or  three  pints  of  dextrose  solution  (2  J 
per  cent.),  in  normal  saline,  may  be  intravenously  infused.  The  body 
must  be  kept  warm. 

4.  Rapidity  of  operation  should  be  aimed  at,  and  no  attempt  made 
to  complete  the  operation  by  radical  cure  at  the  moment  if  the  patient 
is  showing  signs  of  exhaustion. 

5.  Since  the  condition  of  the  bowel  is  always  an  unknown  quan- 
tity, nothing  should  be  overlooked  in  the  way  of  apparatus,  when  it  is 
obtainable,  which  may  be  required  for  the  drainage,  resection,  or 
anastomosis  of  the  bowel.  In  emergencies,  however,  wide  rubber  tubing 
may  take  the  place  of  a  Paul's  tube ;  and  flat  pieces  of  wood,  their 
ends  surrounded  by  rubber  bands,  make  excellent  intestinal  clamps. 

6.  Neither  purgatives  nor  enemata  should  be  given  ;  the  former 
are  dangerous  and  useless,  and  the  latter,  being  retained,  as  they  are 
sure  to  be,  will  probably  be  voided  on  the  table. 

Kelotomy. — The  incision  should  in  all  cases  be  a  wide  one; 
much  time  may  be  lost  in  attempting  to  operate  through  a  cramped 
space.  All  structures  are  divided  down  to  the  sac  itself,  from  which 
they  should  be  separated,  provided  the  patient's  condition  does  not 
compel  haste.  The  fundus  of  the  sac  is  then  caught  up  in  three  pairs 
of  pressure  forceps,  and  is  opened.  This  must  be  done  carefully  with 
the  edge  (not  the  point)  of  the  scalpel,  the  flat  of  the  blade  lying  on 
the  surface  of  the  sac  ;  unless  this  is  done,  there  is  danger  of  the  bowel 
being  carried  by  the  sudden  rush  of  fluid  under  tension  in  the  sac, 
or  by  the  sudden  expansion  of  flatus,  against  the  point  of  the  knife, 
and  so  being  injured.     The  escaping  fluid  should  be  caught  on  a  pad 


OPERATIONS    FOR    STRANGULATFI  >    III  KM  \       649 

and  its  colour  and  smell  noted.  If  it  be  turbid,  blood-stained,  or 
Esculent,  oare  should  be  observed  in  handling  the  bowel,  since  such 
Bigns  point  to  ulceration  at  the  point  of  constriction;  no  attempt 
should  be  made  as  yet  to  draw  down  the  bowel  for  inspection,  in  view 
of  this  possibility.  The  sac  is  opened  to  the  neck,  and  the  colour 
and  surface  of  the  bowel  or  of  the  omentum  must  be  noted.  The 
bowel  must  now  be  released  by  division  of  the  constriction,  the  method 
depending  on  the  variety  of  hernia. 

In  inguinal  hernia. — If  the  hernia  is  an  oblique  one,  a  Cooper's 
hernia  director  is  passed  along  between  the  bowel  and  the  neck  of 
the  sac,  so  that  its  groove  faces  the  anterior  superior  spine  ;  the  hernia 
knife  is  passed  along  it  on  the  flat,  and  the  back  of  the  knife  being 
1  in  iied  into  the  groove,  the  two  instruments  are  pushed  along  together, 
their  handles  more  or  less  widely  separated  according  to  the  depth  of 
incision  required.  In  this  way  the  neck  of  the  sac  is  divided  upwards 
and  outwards  so  as  to  avoid  the  deep  epigastric  vessels  which  lie  along 
its  inner  side.  If  the  hernia  is  a  direct  one,  the  incision  must  be 
made  upivards  and  inivards,  the  director  being  passed  along  the  inner 
aspect  of  the  bowel.  In  spite  of  the  width  of  the  director,  bowel  will 
at  times  tend  to  overlap  its  edges,  especially  in  wide-necked  sacs  with 
much  bowel  ;  the  greatest  care  must  be  taken  in  these  cases  not  to 
injure  the  latter. 

In  femoral  hernia. — Here  the  structure  to  be  divided  is  Gim- 
bernat's  ligament,  which  lies  just  internally  to  the  neck  of  the  sac. 
In  doing  this  the  occasional  peculiar  origin  of  the  obturator  artery 
from  the  deep  epigastric  must  be  remembered.  This  vessel  should 
arise  from  the  anterior  branch  of  the  internal  iliac  artery,  giving  off, 
just  before  it  enters  the  foramen,  the  little  pubic  branch  which  anasto- 
moses with  the  pubic  branch  of  the  deep  epigastric.  Occasionally 
this  branch  may  be  so  large,  and  the  obturator  itself  so  small,  that 
the  latter  may  be  said  to  arise  from  the  deep  epigastric.  In  this  case 
the  vessel  will  be  found  to  occupy  one  of  three  positions  :  (a)  It 
may  lie  at  some  distance  internally  to  the  sac  ;  (b)  it  may  cross  the 
posterior  aspect  of  Gimbernat's  ligament ;  or  (c)  it  may  closely  follow 
its  external  margin,  hugging  the  neck  of  the  sac.  In  the  last  position 
it  would  almost  certainly  be  divided  in  the  act  of  incising  the  con- 
striction. Statistics  as  to  the  frequency  of  this  accident  do  not  help 
to  prevent  its  occurrence  ;  the  constriction  must  be  divided,  and  if 
by  chance  the  accident  should  happen,  three  courses  are  open  to  the 
surgeon  :  (a)  The  bowel  being  returned,  an  effort  may  be  made  to 
catch  the  vessel  in  the  wound — a  very  difficult  matter  owing  to  the 
narrowness  and  depth  of  the  latter.  (6)  The  deep  epigastric  may  be 
tied ;  this  'may  fail  owing  to  the  free  collateral  circulation  here, 
(c)  The  tying  of  the  deep  epigastric  may  be  supplemented  by  ligature 


65o  HERNIA 

of  the  external  iliac  artery.  Fortunately  the  accident  is  of  rare 
occurrence  ;  it  may  to  some  extent  be  avoided  by  using  a  hernia  knife 
with  a  slightly  blunted  edge,  since  the  tense  ligament  is  more  readily 
cut  than  the  lax  vessel.  The  director  should  be  passed  with  the 
groove  facing  the  pubic  spine,  and  the  incision  made  directly  inwards, 
no  more  being  done  than  is  necessary  to  free  the  bowel. 

In  umbilical  hernia. — The  incision  may  be  made  upwards  or 
downwards,  usually  without  danger  ;  the  director  is  rarely  necessary, 
since  the  constriction,  being  due  to  the  fibres  of  the  linea  alba,  can  be 
divided  from  without ;  if  there  is  still  a  constriction  due  to  the  neck 
of  the  sac,  this  too  can  be  dealt  with  from  without. 

Operative  treatment  of  obturator  hernia. — For  reasons 
already  given  (see  p.  606),  this  hernia  is  rarely  submitted  to  operation 
except  when  strangulated.  The  skin  incision  should  be  made  vertically 
downwards  and  inwards  from  a  point  1  in.  external  to  the  pubic 
spine,  for  a  distance  of  5  or  6  in.  This  will  he  along  the  inner 
edge  of  the  femoral  vein.  The  femoral  vessels  are  retracted  outwards 
and  a  separation  is  effected  between  the  adductor  longus  and  pectineus 
muscles.  The  bulging  of  the  hernial  sac  either  through  the  obturator 
canal  or  through  the  muscle  fibres  should  now  be  seen.  If  access 
to  the  parts  is  difficult,  the  fibres  of  the  pectineus  muscle  may  be 
divided,  care  being  taken  to  avoid  its  nerve  which  lies  behind  it.  If 
an  attempt  to  reduce  the  hernia  fails,  a  hernia  director  is  passed  along 
the  neck  of  the  sac  above  or  belov:,  and  the  hernia  knife  passed  along 
it  so  as  to  divide  the  constriction  either  upwards  or  downwards,  the 
vessels  usually  lying  anteriorly  or  posteriorly  to  the  neck  of  the  sac. 
Failing  success  in  reduction  by  this  method,  the  abdomen  should  be 
opened  to  the  hernial  side  of  the  middle  line,  and  reduction  effected 
by  gentle  traction  from  within,  the  greatest  care  being  taken  not  to 
rupture  the  bowel,  nor  to  allow  of  the  escape  of  foul-smelhng  or  blood- 
stained fluid  into  the  abdominal  cavity.  The  sac  is  then  transfixed, 
tied,  and  removed,  and  the  wound  is  closed. 

Gluteal  and  sciatic  hernias  can  be  released  by  a  downward 
incision,  but  in  these  cases  the  irregularity  of  the  vascular  anastomosis 
mav  be  considerable,  and  the  best  rule  is  that  of  free  access  to  the 
parts  by  a  wide  incision,  the  division  being  effected  by  careful  dissection. 

Is  the  bowel  recoverable? — As  soon  as  the  constriction 
has  been  divided,  the  state  of  the  bowel  must  be  ascertained.  It 
should  be  gently  withdrawn  from  the  wound,  remembering  always 
that  the  release  must  be  sufficiently  free  to  permit  of  this  being  done 
without  the  least  force  ;  for  if  at  this  moment  a  tear  shoidd  occur  at 
the  constriction,  the  bowel  above  being  tensely  filled  with  liquid 
faeces  and  flatus,  the  lower  abdomen  is  immediately  flooded  and  the 
patient's  doom  is  sealed. 


REGOVERABILITY   OF   How  I  I  651 

Bowel  may  be  classified  as  "safe,"  "doubtful,"  01  "dangero 
It  is  "safe"  when     (1)  there    is   no    Lymph  on    its   surface;  (2)    it 
has  not  Losl  its  gloss ;   (3)  oedema  and  bogginess  are  absenl  ;    (4)  there 
is  ueither  eoohymosis  aor  oonstriotion-slough  at,  or    near  the  aeok  ; 

(5)  it  gradually  returns  to  its  normal  colour  on  being  released  ;  (6)  the 
mesentery  is  aoi  discoloured  by  blood  extravasation  ;  (7)  the  Quid  in 

t  he  sac  is  dear  and  tree  from  odour. 

It  is  "doubtful"  if— (1)  there  is  much  delay  in  the  return  of 
colour  on  being  released;  (2)  it  has  lost  its  gloss;  (3)  the  fluid  is 
blood-stained. 

It  is  "dangerous"  when — (1)  it  is  black  and  boggy;  (2)  fin- 
constriction  remains  clearly  outlined  on  the  surface;  (3)  the  fluid  is 
foul  and  blood-stained. 

"Safe"  intestine  may  be  returned  to  the  abdomen  after  being 
gently  washed  with  normal  saline  at  a  temperature  of  110°  F.  ;  after 
which,  if  the  patient's  condition  is  good,  the  usual  radical  operation 
may  be  performed.  Otherwise,  the  wound  is  closed  and  a  pad  applied 
to  prevent  the  return  of  the  hernia  ;  the  radical  operation  being  deferred 
till  later. 

"  Doubtful  "  or  "  dangerous  "  bowel. — Two  courses  are  open  to  the 
surgeon  here.  He  may  either  resect  the  strangulated  portion,  reuniting 
the  cut  ends  by  some  form  of  intestinal  anastomosis,  or,  fixing  the 
loop  in  the  wound,  he  may  open  it  and  introduce  a  Paul's  tube.  The 
choice  of  method  will  depend  chiefly  on  the  condition  of  the  patient. 
Resection  is  the  ideal  method  and  should  be  done  even  where  the 
bowel  is  "  doubtful,"  but  the  decision  to  attempt  it  must  be  influenced 
also  by  (1)  the  length  of  bowrel  to  be  resected  ;  (2)  the  portion  of  the 
bowel  involved  ;  (3)  the  character  of  the  strangulation  ;  (4)  the  expe- 
rience of  the  operator  ;  (5)  the  availability  of  skilled  assistance  ;  and 

(6)  the  patient's  surroundings,  as  regards  light,  cleanliness,  and  materials 
for  so  serious  an  operation.  Roughly  speaking,  resection  is  indicated 
(a)  where  the  patient  is  not  over  60,  is  not  exhausted  by  vomiting, 
and  cardiac  and  pulmonary  disease  are  absent ;  (6)  where  the  small 
intestine  is  involved  ;  (c)  where  the  amount  of  bowel  involved  is  not 
so  great  as  to  preclude  the  possibility  of  success  ;  *  (d)  where  the 
operation  is  done  by  one  skilled  in  surgical  technique  and  rapid 
operating ;  and  (e)  where  it  can  be  done  under  spinal  analgesia. 
Strangulated  omentum  should  always  be  resected. 

Formation    of   a    faecal    or    intestinal    fistula. — This 

1  A  length  of  anything  over  3  feet  must  be  looked  upon  as  serious,  although 
as  much  as  11  feet  has  been  successfully  removed.  Spinal  analgesia  has  greatly 
lessened  the  danger  of  resection;  thus,  in  the  Seamen's  Hospital,  Gwynne 
Williams  has  successfully  resected  7  feet  of  small  intestine  under  its  influence 
in  a  patient  of  over  GO,  without  increase  of  shock,  although  the  strangulation 
was  a  double  one. 


652  HERNIA 

is  the  only  safe  treatment  where  the  patient  is  old,  feeble,  and 
exhausted  by  pain  and  vomiting,  and  where  the  mass  is  too  great  for 
resection  and  anastomosis.  It  should  also  be  done,  as  a  rule,  in 
strangulation  of  the  large  bowel,  in  preference  to  primary  resection, 
which  has  a  higher  mortality  than  in  the  case  of  the  small  bowel,  because 
(1)  the  blood  supply  is  less  extensive  and  more  longitudinal,  and  there- 
fore union  is  more  difficult  to  secure  ;  (2)  the  contents  are  more  solid 
and  therefore  more  irritating ;  (3)  the  arrangement  of  the  musculature 
is  less  adapted  to  anastomosis  ;  and  (4)  flatus  accumulates  with  greater 
rapidity  here. 

It  should  not,  however,  be  done  when  there  is  reason  to  suppose 
that  the  strangulation  is  high,  for  although  life  can  be  saved  by 
artificial  feeding  through  the  jejunum  for  a  considerable  period,  as 
proved  by  me  in  conjunction  with  Bruce  Clarke,  it  is  extremely 
difficult,  and  would  not  succeed  in  all  cases  alike. 

Points  regarding  the  methods  of  operating. — When 
resection  and  anastomosis  is  proposed  in  the  case  of  inguinal  or 
femoral  hernia,  it  is  better  that  the  operation  should  be  done  in  situ 
than  that  the  abdomen  should  be  opened  and  the  damaged  bowel 
withdrawn  through  the  abdominal  wound  for  the  purpose.  When 
a  perforation  exists  there  is  danger  of  soiling  the  peritoneum ;  while 
even  when  none  is  present,  the  manipulation  necessary  to  reduce  the 
damaged  bowel,  especially  when  wrapped  in  gauze  as  a  precautionary 
measure,  is  likely  to  result  in  a  tear  and  in  extravasation  of  the  contents. 
In  performing  the  anastomosis  the  hernial  aperture  must  be  enlarged, 
the  bowel  must  be  well  drawn  through  the  ring  from  the  abdomen, 
thoroughly  cleansed,  and  reduced.  Where  foul  fluid  is  present,  a  light 
gauze  wick  or  a  "  cigarette  "  drain  should  be  placed  in  the  wound  for 
twenty-four  hours. 

The  surgeon  may  be  faced  with  the  difficulty  of  dealing  with  a 
section  of  intestine  which  is  gangrenous,  or  at  least  "  dangerous," 
at  two  or  more  points.1  He  must  rapidly  determine  on  one  of  three 
courses  :  he  must  either  (a)  perform  two  or  more  separate  resections  ; 
(b)  resect  the  whole  length  of  bowel  involved  ;  or  (c)  bring  the  whole 
length  outside  the  abdomen  and  make  an  intestinal  fistula  or  an 
artificial  anus.  Each  case  must  be  judged  on  its  merits,  and  the 
following  points  will  help  in  the  decision  : — 

1.  A  large  section  may  be  resected  and  an  anastomosis  performed 
more  rapidly  than  two  short  sections  ;  thus  a  prolonged  operation 
is  avoided. 

2.  When,  however,  the  section  to  be  removed  is  very  long  (6  to 
8  ft.)  the  shock  may  be  equally  great ;  in  even  longer  sections  it  may 
be  much  greater  than  from  the  resection  of  two  separate  sections. 

1  This  was  so  in  Williams's  case,  referred  to  on  p.  651  (footnote). 


EXCLUSION    OF   GANGRENOUS    BOWEL 


653 


3.  When  the  gangrenous  portions  are  utuated  one  in  the  small 
and  the  other  in  the  Large  bowel,  the  former  may  be  resected  and  the 
latter  converted  into  an  artificial  anus  for  the  time  being,  when  the 
patient  cannot  stand  two  resections. 

I.  Extensive  resections  are  attended  by  a  mortality  which  ia 
largely  in  inverse  ratio  to  the  skill  and  rapidity  of  the  operator.  For 
tins  reason,  in  unpractised  hands,  the  emergency  is  besl  met  by  the 
third  method,  viz.  exclusion  of  the  affected  loop  and  the  formation  of 
an  intestinal  fistula. 

For  this  purpose,  the  sound  bowel  having  been  brought  down  to 


Fig.  475. — Exclusion  of  gangrenous  bowel  and  formation  of 
intestinal  fistula. 

a.  Sutures  joining  loops  ;  /■,  b,  gangrenous  sections  ;  c,  rod  supporting  bowel  ;  if,  bowel  clamp  : 

t.  <■.  1  .  1 ,  ligatures  on  bowel  :  f,f,  Paul's  tubes  in  cut  ends;  gt  Paul's  tube  in  excluded  loop  ; 

//,  site  of  incision  in  loop. 

the  ring,  the  entering  and  returning  coils  are  connected  side  by  side 
by  one  or  two  interrupted  sutures  (Fig.  475,  a)  some  distance  from  the 
gangrenous  portions  (6),  and  are  supported  by  a  short  length  of  rubber- 
covered  glass  rod  (c)  passed  beneath  the  union.  A  clamp  (d)  is  applied 
just  distally  to  the  union,  and  a  ligature  (e)  is  placed  round  each 
portion  of  the  bowel  about  lh  in.  beyond  the  clamp.  Finally, 
the  bowel  is  divided  between  the  clamp  and  the  ligatures  ;  a  Paul's 
tube  (/)  is  introduced  into  each  cut  end,  being  fixed  by  a  purse-string 
suture,  and  the  clamp  is  removed.  An  incision  should  be  made  into 
the  loop  at  the  point  (h),  and,  if  necessary,  a  third  Paul's  tube  (g)  intro- 
duced to  prevent  it  from  becoming  distended  with  gas  and  fluid.     The 


654  HERNIA 

fistula  may  be  rapidly  made  in  this  way,  and  the  loop  with  its  mesentery 
raayte  removed  on  recovery  of  the  patient  at  the  end  of  three  or  four 
days  ;  the  anastomosis  may  be  deferred  till  later  unless  the  fistula 
is  high  up  in  the  bowel,  when  it  should  be  done  at  the  earliest  possible 
date.  It  may  even  be  done  at  the  time  of  the  first  operation  ;  in  this 
case  a  lateral  anastomosis  by  means  of  a  Murphy's  or  a  Jaboulay's 
button  is  the  method  indicated. 

"Where  the  case  is  so  urgent  as  to  demand  it,  the  loop  must  be 
secured  to  the  skin  incision  and  the  Paul's  tube  inserted  without  the 
above  elaboration.  The  making  of  an  intestinal  fistula  in  situ  in  the 
case  of  femoral  hernia  is  attended  by  certain  difficulties  :  the  proximity 
of  the  femoral  and  saphenous  veins  renders  the  femoral  canal  a  bad  site 
for  the  discharge  of  faeces  ;  moreover,  the  canal  is  often  too  long  and 
narrow  to  allow  of  satisfactory  evacuation  of  the  bowel,  or  its  reduction 
from  within  by  laparotomy,  when  swathed  in  gauze.  In  such  a  case, 
where  the  patient  is  able  to  stand  it,  the  abdomen  may  be  opened 
above  the  pubes  ;  the  gangrenous  loop  and  its  mesentery  are  sur- 
rounded  by  a  double  ligature  and  divided  between,  the  mass  being 
cut  away.  The  cut  ends  are  then  washed,  swabbed  over  with  pure 
carbolic  acid,  washed  again,  and  seized  with  a  clamp  and  drawn  through 
the  wound  into  the  abdomen,  the  remaining  bowels  being  kept  out  of 
the  way  as  far  as  possible  ;  finally,  the  ends  are  brought  out  of  the 
abdominal  wound,  and  are  treated  by  anastomosis,  or  with  Paul's  tubes, 
in  the  manner  above  described. 

After-treatment  of  strangulated  hernia. — The  in- 
dications are — to  combat  shock,  support  the  patient's  strength,  and 
provide  against  complications. 

In  a  quite  uncomplicated  case  nothing  more  is,  as  a  rule,  necessary 
than  to  secure  sleep  and  provide  fluid  diet.  The  bowels  should  be 
moved  at  first  only  by  enemata,  and  after  forty-eight  hours  by  calo- 
mel given  in  grain  doses  every  hour  up  to  5-8  gr.,  this  being 
assisted  when  needful  by  a  dose  of  salts,  or  Apenta  or  other  mineral 
water.  Strychnine  hypodermically  or  nux  vomica  by  the  mouth  will 
lessen  the  chances  of  paralytic  ileus  ;  by  some,  pituitary  extract  or 
eserine  salicylate  given  hypodermically  is  thought  to  be  also  of  use. 

Where  there  has  been  severe  strangulation  with  fseculent  vomit, 
infusion  with  normal  saline  or,  better  still,  dextrose  saline  intra- 
venously (2-5  per  cent.)  or  per  rectum  (8  per  cent.),  should  be 
practised.  Two  or  three  pints  may  be  given  intravenously ;  but, 
per  rectum  the  continuous  method  should  be  used,  the  solution  being 
introduced  at  the  rate  of  half  a  pint  an  hour,  till  the  blood  pressure 
is  sufficiently  raised.  The  addition  of  adrenalin  solution,  1  drachm  to 
the  pint,  will  often  help  considerably  in  the  intravenous  method. 

If  not  done  before  operation,  the  stomach  should  be  washed  out  as 


AFTER-TREATMENT  OF  STRANGULATION 

soon  as  the  patient's  condition  admits  of  it,  and  Balol  in  5-grain  'I"  as 
administered.  The  semi  recumbent  position  (Fig.  466,  p.  639)  should 
be  adopted,  and  the  expectoration  of  fseoulenl  sputum  encouraged 
by  the  use  of  ammonium  carbonate  in  5-grain  doses,  01  othei  suitable 
drug. 

When  resection  and  anastomosis  lias  been  performed,  it  is  in  the 
highest  degree  important  to  prevent  any  distension  of  the   bowel; 
this  is  best  accomplished   by  the  use  of  the  soft  rectal  tube  pi 
high  and   retained  in  situ,  or  by  the  occasional  use  of  enemata  of 
turpentine  or  asafcetida. 

The  feeding  of  these  patients  is  not,  as  a  rule,  difficult.  Wnere 
no  damage  to  the  bowel  has  occurred  it  may  be  carried  out  on  ordinary 
lines.  When  resection  and  anastomosis  has  been  done,  nothing  but 
fluids  should  be  given  for  at  least  forty-eight  hours.  Albumin  water, 
beef-juice,  egg-flip,  white  wine  whey,  Brand's  jelly,  veal  or  chicken 
jelly,  junket,  calf's-foot  jelly,  etc.,  may  be  given  ;  dextrose  solution  per 
rectum  is  in  itself  a  food,  and  has  a  very  high  calorific  value.  On  the 
fourth  day,  if  the  patient  is  progressing  well,  Benger's  food,  pounded 
fish  or  chicken,  etc.,  may  be  given  in  small  quantities  frequently. 
Full  diet  should  not  be  allowed  for  a  fortnight  from  the  time  of 
operation. 

Opium  and  morphia  are  best  avoided  ;  they  mask  symptoms  and 
cause  constipation.  Pain  must  be  relieved,  if  possible,  by  aspirin  in 
10-grain  doses,  and  sleep  provided  by  such  drugs  as  veronal  5  gr., 
chloralamide  30  gr.,  or  trional  20  gr.  When  the  case  has  ended  in 
the  establishment  of  an  intestinal  fistula,  the  bowels  may  be  cleared 
out  at  once,  and  feeding  started  as  soon  as  the  stomach  has  been 
cleansed  and  the  sickness  has  ceased. 

In  the  event  of  recovery  the  Paul's  tube  will  become  detached  in 
about  three  days,  and  the  question  will  then  arise  as  to  the  reconstitution 
of  the  bowel.  This,  unless  the  stoma  is  high  in  the  canal  (jejunum), 
should  not  be  attempted  before  the  strength  is  recovered,  since  there 
is  a  danger  of  union  failing  owing  to  weakness  and  anaemia.  In  the 
higher  regions  the  attempt  must  be  made  at  the  earliest  possible  date 
by  simple  suture  without  detachment  of  the  skin  union  ;  failing  this, 
detachment  should  be  done,  and  the  lips  of  the  bowel  wound  should 
be  inverted  by  two  rows  of  Lembert's  sutures.  Where  this  fails,  or 
where  there  is  a  marked  "  spur,"  resection  and  anastomosis  affords 
the  only  chance  of  arresting  the  rapid  emaciation  which  occurs.  The 
abdominal  wound  should  not  be  closed  in  these  cases,  as  the  tissues 
are  obviously  infected  ;  it  should  be  allowed  to  close  by  granulation, 
any  subsequent  hernia  being  cured  by  filigree-implantation. 

After-complications  of  kelotomy  for  strangulated 
hernia. — 1.  Septic     broncho-pneumonia     is    not    infrequent    when 


656  HERNIA 

faecal  vomiting  has  occurred.  The  prognosis  is  grave,  especially 
in  elderly  subjects,  and  the  case  may  progress  to  abscess  and  gangrene 
of  the  lung. 

2.  General  peritonitis  may  result  from  subsequent  sloughing  or 
perforation  of  the  returned  bowel.  The  only  possible  treatment  is 
immediate  laparotomy  and  cleansing  of  the  abdomen,  the  bowel  being 
brought  into  the  wound  as  already  described,  and  the  abdomen  drained 
through  both  loins  and  above  the  pubes.  The  prognosis  is  usually 
fatal,  recovery,  when  it  occurs,  depending  on  the  interval  which  has 
elapsed,  the  amount  of  extravasation,  and  the  strength  of  the  patient. 

3.  Paralytic  ileus  may  supervene  on  release  of  the  strangulation, 
or  may  be  actually  present  when  the  case  is  first  seen,  the  vomiting, 
distension,  and  inability  to  pass  flatus  persisting.  No  time  should 
be  lost  in  opening  the  caecum,  or  lower  end  of  the  ileum.  Owing  to 
the  vomiting,  drugs  can  seldom  be  given  by  the  mouth,  and,  if  the 
ileus  is  absolute,  little  can  be  done.  When  the  strangulation  has  been 
seen  late  in  the  case  this  danger  is  to  be  feared  ;  it  is  well  to  open  the 
abdomen  by  a  small  incision  above  the  umbilicus,  and,  drawing  out 
a  loop  of  the  jejunum,  to  inject  into  it  3  or  4  drachms  of  magnesium 
sulphate  with  10  minims  of  tincture  of  nux  vomica,  closing  the  puncture 
by  a  fine  purse-string  suture.  Puncture  of  the  coils  of  intestine  by 
means  of  a  trocar  and  cannula  is  a  tedious  process,  and  seldom 
succeeds.  The  prognosis  is  commonly  fatal,  and  prophylaxis  is  better 
than  attempts  at  cure.     Eserine  or  pituitrin  hypodermically  will  help. 

4.  Stenosis  may  occur  at  the  site  of  constriction,  or  when  anasto- 
mosis has  been  performed,  especially  when  a  Murphy's  button  has 
been  used.  In  a  case  of  my  own,  stenosis  followed  simple  reduction 
four  months  after  operation  in  another  hospital,  and  resulted  in 
adhesion  to  the  abdominal  wall,  ulceration  above  the  constriction, 
and  a  faecal  abscess  of  the  abdominal  wall.  This  necessitated  excision 
of  the  caecum,  appendix,  and  ten  inches  of  ileum,  and,  on  recovery, 
the  cure  of  the  resulting  hernia  by  implantation  of  a  large  abdominal 
filigree. 

Symptoms  of  dyspepsia,  distension,  anorexia,  and  constipation 
should  suggest  the  possibility  of  this  complication,  especially  where 
the  bowel  has  been  slow  in  recovering  its  vitality  at  the  original 
operation. 

Prognosis  in  strangulated  hernia. — The  probabilities  of 
recovery  in  an  uncomplicated  case  depend  on  the  duration  and  character 
of  the  vomiting,  the  age  of  the  patient,  and  his  general  condition.  Up 
to  the  time  of  the  vomit  becoming  faeculent  the  patient  is  well  within 
the  period  of  grace  ;  when  this  point  has  been  passed  and  the  odour 
of  the  vomit  shows  the  presence  of  jejunal  contents,  the  prognosis 
must  be  considered  grave,  especially  if  the  vomit  is  copious,  frequent, 


PROGNOSIS    IN   STRANGULATED    HERNIA       657 

and  Eorcible  ;  when  the  vomil  is  actually  Eseoal  the  time  of  grade  has 
passed,  and,  aa  Kandley  has  pointed  out,  this  si^n  must  be  looked 
upon  as  a  prasagium  mortis. 

The  older  the  patient,  the  worse  the  prognosis,  since  in  these  cases 
exhaustion  sets  in  rapidly,  and  the  inability  to  expectorate  the  foul 
sputum  and  minus  from  the  larynx  is  very  distressing. 

When,  in  a  strangulated  hernia  of  some  standing,  and  in  which 
vomiting  has  been  active  the  vomiting  suddenly  ceases,  the  patient 
going  into  collapse  or,  as  sometimes  happens,  saying  he  feels  better, 
a  grave  suspicion  should  be  entertained  of  rupture  or  perforation  of 
the  bowel. 

Elderly  subjects  are  more  affected  by  the  shock  of  a  tight  con- 
striction than  are  young  adults,  and  the  exhaustion  produced  by  the 
vomitless  retching  of  a  high  jejunal  strangulation  is  in  them  more 
profound  than  when  the  vomit  is  in  quantity  and  possibly  even 
f  feculent. 

In  cases  complicated  by  gangrene,  perforation,  and  peritonitis,  01 
in  which  resection  has  been  performed,  it  is  obvious  that  the  gravity 
of  the  prognosis  will  be  proportionate  to  the  duration  and  height  of 
the  strangulation,  the  period  elapsing  between  perforation  and 
operation,  and  the  length  of  the  section  of  bowel  removed. 

BIBLIOGRAPHY 

Bartlett,  Willard,  Journ.  of  Amer.  Med.  Assoc,  1903,  i.  47. 

Bonney,  Victor,  Arch,  of  Middx.  Hosp.,  Nov.,  1910,  p.  27. 

Clarke,  Bruce,  Lancet,  1907,  i.  8. 

Graser,  von  Berginann's  System  of  Surgery,  iv.  622. 

McGavin.  Lawrie.  Trans.  Clin.  Soc,  1907,  p.  134  ;    Trans.  Boy.  Soc.  Med.,  Clin.  Sec, 

1909,  ii.  156:    Lancet,  1907,  ii.  1445;    Brit.  Med.   Journ.,    1907,  ii.    1395; 

Aug.  14,  1911. 
Mayo,   William,  Ann.  of  Surg.,  1901,  ii.  276;   Journ.  of  Amer.  Med.  Assoc,  July, 

1903. 
Richards,  Owen,  Lancet,  1899,  ii.  1386. 

Russell,  Hamilton,  Lancet,  1899,  ii.  1353  ;   1902,  i.  1519  ;   1904,  i.  707. 
Sultan,  Saunders'  Hand-Atlas,  "  Hernia,"  p.  106. 


THE  RFXTUM  AND  ANAL  CANAL 

By  H.  S.  CLOGG,  M.S.Lond.,  F.R.C.S.Eng. 

Anatomy. — The  rectum  commences  in  front  of  the  3rd  (sometimes 
the  2nd)  sacral  vertebra,  and  ends  by  passing  through  the  pelvic 
diaphragm,  about  1|  in.  below  and  in  front  of  the  tip  of  the  coccyx, 
opposite  the  lower  part  of  the  prostate  in  the  male,  and  the  lower 
fourth  of  the  vagina  in  the  female.  It  lies  entirely  within  the  pelvic 
cavity,  and  measures  about  6  in.  in  the  adult.    Its  relations  are  seen 


Fig.  476. — Male  pelvis  in  vertical  median  section,  showing  the 
rectum'and  anal  canal  in  section,  their  anterior  and  posterior 
relations,  and  the  recto-vesical  reflexion  of  the  peritoneum. 

658 


ANATOMY 


in  Figs.  I7<i.  177.  and  178.  Narrowesl  above,  it  frequently  shpws,a 
distincl  constriction  a1  its  junction  with  the  pelvic  eolon,  and  here 
a  physiological  sphincter  exists,  for  the  rectum  is  a  passage,  and  not 
i  reservoir,  Eor  faeces.  Jusl  above  its  termination  a  dilatation  known 
is  i  he  ampulla  is  presenl . 

The  upper  part,   excepl    .1    tow  strip  of  posterior  surface,  is 

covered  with  peritoneum.  The  serous  membrane  gradually  leaves 
the  sides,  and  finally  the 
anterior  wall  ;  the  level  of 
reflexion  varies  slightly, 
but  is  commonly  about  3 
in.  from  the  anal  margin  ; 
in  the  child  it  is  relatively 
lower  than  in  the  adult. 
The  peritoneum  is  intim- 
ately attached  to  the  bowel 
above,    but    more    loosely 

In 'low. 


The    longitudinal     muscle 
fibres  are  principally  collected 
into  an  anterior  and   a  pos- 
terior bundle,  which   are  re- 
latively    shorter     than     the 
rectum    itself ;     hence    when 
distended    the    bowel    shows 
lateral  inflexions  of  its  walls. 
The  circular  muscle  fibres  form 
a  complete  investment.     The 
thick,    vascular  mucosa    pre- 
sents numerous    folds   in  the 
empty  gut.     Lymphoid  nod- 
ules are  found  in  the  mucosa  Fig.  -477. — Female  pelvic  viscera  in  verti- 
and  submucosa ;  Lieberkuhn's       cal  section,  showing  the  relation  of  the 
follicles   are    abundant ;    the        rectum   to   the    vagina    and    the    recto- 
surface     epithelium     is     co-       vaginal  reflexion  of  the  peritoneum, 
lumnar. 

The  rectal  valves  (valves  of  Houston,  Fig.  479)  are  circular,  crescentic,  or 
spiral  folds,  best  seen  in  the  distended  gut,  and  composed  of  all  the  tissues  of 
the  bowel  wall,  except  perhaps  some  of  the  outer  longitudinal  muscle  fibres. 
They  correspond  in  position  to  the  lateral  inflexions  of  the  wall,  and  have  a 
similar  origin.  There  are  commonly  one  well-marked  right  valve  and  two 
less  definite  left  ones,  the  former  being  immediately  above  the  peritoneal 
reflexion  and  the  latter  equidistant  above  and  below  it. 

The  anal  canal  is  an  antero-posterior  slit-like  passage,  about  1  in.  long, 
leading  downwards  and  backwards  to  the  anal  orifice,  and  forming  an  angle 
of  90°  with  the  rectum  (Fig.  476).  On  each  side  is  the  ischio-rectal  fossa  ;  in 
front  the  membranous  urethra  and  its  enclosing  muscles  in  the  male,  and 
in  the  female  the  perineal  body,  separating  it  from  the  vagina  ;  behind  is 
a  mass  of  muscular  and  connective  tissue— the  ano-coccygeal  body.     The 


66o 


RECTUM    AND    ANA  I.    CANAL 


longitudinal  muscle  fibres  of  the  rectum  are  prolonged  as  a  thin  investment 
to  the  canal,  and  the  levator  ani  also  encloses  it.  The  circular  muscle  fibres 
are  considerably  thickened,  and  constitute  the  internal  sphincter.  This  is 
about  1  in.  in  vertical  extent,  and  is  easily  detected  on  digital  examination. 
Being  merely  a  thickening  of  circular  muscle  fibres,  it  should  have  a  similar 
action,  and  should,  therefore,  empty  the  bowel  (Cunningham).  Clinical 
experience,  however,  teaches  that 
whereas  the  external  sphincter  may 
be  cut  with  impunity,  division  of 
both  sphincters  may  cause  faecal 
incontinence. 


Fig.  478.  ^Base  of  the  bladder, 
vesiculae  seminales,  vasa  de- 
ferentia,  ureters,  prostate, 
membranous    urethra,    and  Fig-  479. — The  rectum  opened 

bulb  of  the  corpus  spongio-  anteriorly. 

SUm,  tO  Show    the    Structures  ,,.  Peritoneum  of  the  anterior  and  lateral  walls  of 

in  relation  anteriorly   to   the  the  rectum,  and  the  lower  limit  anteriorly  j  h.,  the 

male  rectum  and  anal  canal.        valves  of  H,ous,0°>  one. of  wYlcha  is.  immediately 

a'  above  the  peritoneal  reflexion. 

The  anal  canal  shows  eight  or  nine  vertical  folds  composed  of  mucous 
membrane  and  muscularis  mucosae— the  columns  of  Morgagni  (Fig.  480). 
These  are  permanent,  not  effaced  by  distension,  well  marked  in  the  foetus, 
and  constant  throughout  life.  Occasionally  they  are  ill  marked,  rarely 
they  are  absent.  The  columns  are  broader  below,  and  gradually  taper  above. 
Their  bases  |  anal  ends)  are  connected  by  a  circumferential  irregular  "  zig-zag  " 


\\  \K>\1Y 


66t 


line  a  little  above  the  anas,  though!  by  some  to  indicate  the  lii 
of  the  hind-gat  and  prootodaeum  (p.  666).  The  intervening  depressions — the 
rectai  sinuses  of  Morgagni — end  abruptly  belovi  and  are  guarded  by  the 
miniature  anal  valves  (the  intercolumnar  portions  oi  the  "zig-zag"  line). 
The  sinuses  and  valves  \  ary  in  development,  andarebettei  marked  posteriorly. 
The  appearance  below  the  "zig-zag"  line  is  whitish,  resembling  modified 
skin,  whilst  above  it  resembles  modified  mucous  membrane.  Squamous 
epithelium  lines  the  lower  pari  of  the  canal,  and  extend'-  to  the  bases  of  the 
columns,  columnar  epithelium  extending  to  the  sinuses.  The  transformation 
of  epithelium  is  a  gradual  one.     Sometimes  minute  tiny  pits  or  depressions 


LA. 


Fig.  480. 


E.5. 


5.  V. 

— The  lower  rectum  and  anal  canal,  incised 
longitudinally  and  held  widely  open. 


E.S.,  External  sphincter  muscle  ;  i.s.,  internal  sphincter  muscle  :  L.A..  ie\at  >r  ani  muscle 
M.,  columns  of  Morgagni  :  s.,  sinus  of  .Morgagni  ;  v.,  anal  valve. 

are  seen  on  the  mucosa  of  the  lower  rectum  and  anal  canal.  It  has  been 
stated  that  infective  diseases  may  originate  in  these  depressions. 

Muscles  and  fasciae. — The  external  sphincter  is  a  subcutaneous  muscle, 
about  1  in.  in  breadth,  encircling  the  anus,  attached  posteriorly  to  the  coccyx, 
and  anteriorly  to  the  central  point  of  the  perineum.  It  is  superficial  to  the 
internal  sphincter  muscle,  the  sulcus  between  the  two  being  readily  detected 
on  digital  examination  of  the  anal  canal.  It  overlies  the  fat  of  the  ischio- 
rectal fossa.  It  is  supplied  by  the  inferior  hemorrhoidal  and  perineal  branch 
of  the  4th  sacral  nerves. 

The  levator  ani  and  the  coccygeus  form  the  pelvic  floor  or  diaphragm; 
they  are  enclosed  in  sheaths  derived  from  the  pelvic  fascia,  and  with  their 
fascial  prolongations  help  to  support  the  bowel. 

The  levator  ani  is  attached  to  the  back  of  the  os  pubis  in  front  and  the 
ischial  spine  posteriorly,  and  between  these  two  points  to  the  pelvic  fascia, 
near  its   "  white  line."'      The  fibres  pass   downwards   and   backwards — the 


662 


RECTUM    AND    ANAL    CANAL 


anterior  one-  being  almost  horizontal  and  the  posterior  ones  nearly  vertical — 
to  be  inserted  into  the  central  point  of  the  perineum  and  into  the  wall  of 
the  anal  canal,  blending  with  the  external  sphincter,  while  behind  the  anus 
the  two  muscles  meet  in  a  median  raphe  between  the  anus  and  the  coccyx, 
and  the  most  posterior  fibres  are  attached  to  the  lower  sacral  and  coccygeal 
vertebrae  (Fig.  481).  The  upper  surface  is  separated  by  the  pelvic  fascia 
from  the  prostate,  or  vagina,  and  the  rectum  :  the  inferior  surface,  covered 
by   the   anal   fascia,    hounds   the  ischio-rectal  fossa.      It  is  supplied  by   the 


Fig.  481. — The  ischio-rectal  fossae.     The  attachment  of  the  external 
sphincter  muscle  to  the  coccyx  has  been  removed. 

it..  Ischial  tuberosity-;  S.S.L.,  great  sacro-sciatic  ligament  :  t.k,  transverse  perineal  muscle  ; 
e.s..  external  sphincter  muscle;    l.a..  levator  ani  muscle ;   P.  (on  the  right  side),  the  fascia 
covering  the  ohturator  internus  muscle  ;  F.  (on  the  left  side),  the  cut  edge  of  the  fascia  which 
has  been  removed,  showing  o.t.,  the  obturator  internus  muscle. 

perineal  branch  of  the  pudic  nerve,  and  by  the  3rd  and  4th  sacral  nerves 
on  its  pelvic  aspect. 

The  fibres  of  the  levatores  ani  passing  from  the  back  of  the  os  pubis  to 
meet  behind  the  anus  will,  when  contracted,  firmly  grip  the  anal  canal, 
reducing  it  to  an  antero-posterior  slit.  These  fibres  of  the  levatores,  there- 
fore, form  a  sphincter  to  the  anal  canal,  and  can  often  be  detected  by  digital 
examination  per  rectum. 

The  coccygeus  is  attached  to  the  ischial  spine,  the  adjacent  pelvic  fascia 
and  the  side  of  the  coccvx.     It  is  in  contact  anteriorly  with  the  levator  ani, 


\\\T()\1V  663 

.Hid  posteriorly  with  the  lessei  ktic  ligament     It  i-  supplied  on  its 

pelvic  surface  by  the  3rd  and  4th  Baeral  nerves. 

The  extraperitoneal  tisstu  in  the  pelvis,  almost  devoid  ol  Eat,  extends 
along  the  rectum  as  far  as  the  anal  canal.  It  supports  the  bowel,  and  conveys 
the  vessels  to  the  rectum. 

The  pd\  ■  •'-• '"  lines  tin-  pelvis  ami  supplies  sheaths  for  the  muscles  and 
supports  i"i  the  pelvic  viscera.  Liuin<_r  tin-  levator  ani  on  it-  pelvic  aspect 
1-  a  strong  fibrous  layer,  which  at  tin-  insertion  oi  the  muscle  is  attached 
to  the  deep  layei  oi  the  triangular  ligament,  tin-  bowel  wall,  and  behind  tin- 
is  continuous  with  tin-  layer  "t  the  opposite  side  above  the  raphe  of  insertion 
of  the  levatores  ani  muscles,  and  i-  prolonged  posteriorly  over  the  cot 
muscle.  The  rectum  receives  from  this  layer  a  sheath  which  gradually  thins 
below  and  becomes  lost  where  the  anal  canal  eornmen 

Ischiorectal  fossa  (Fi<_r.  481). — Tin-  fossa,  occupied  by  fat,  is  bounded 
externally  by  the  pelvic  fascia  covering  the  obturator  internus  muscle  ;  inter- 
nally by  the  anal  fascia  elothing  the  levator  ani  and 
anteriorly  by  the  junction  of  the  anal  fascia  and  deep  layer  of  the  triangular 
ligament  ;  posteriorly  by  the  sacro-sciatic  ligament  and  gluteus  maxhnus 
muscle.    T  1  lapped  posteriorly  by  the  gluteus  inaximus,  and 

internally  by  the  external  sphincter;  between  these  bwo  the  subcutaneous 
is  continuous  with  the  ischio-rectal  fat.  The  depth  of  the  fossa  varies, 
but  in  an  average  adult  measures  about  2|  in.  The  pudie  vessels  and  nerve 
run  in  a  fascial  tunnel  in  the  outer  wall  of  the  fossa,  and  the  inferior  hemor- 
rhoidal vessels  and  nerve  cross  the  fat  in  the  fossa. 

Arteries. — The  superior  hasmorrhoidal,  a  continuation  of  the  inferior 
mesenteric  trunk,  supplies  the  muscular  and  mucous  coats  in  the  upper 
part,  and  the  mucosa  only  in  the  lower  inch  or  so,  one  terminal  vessel  being 
found  in  each  column  oi  Morgagni  The  middle  hamorrhoidals,  one  on  each 
side,  from  the  internal  iliac  arteries,  supply  the  muscular  -nails  of  the  lower 
rectum  and  the  mucosa  of  the  upper  anal  canal.  The  inferior  hemorrhoidals, 
two  or  three  on  each  side,  from  the  pudic  vessels,  supply  the  muscles  prin- 
cipally, but  branches  also  pass  to  the  mucosa  through  the  interval  between 
the  two  sphincter  muscles  or  in  the  immediate  neighbourhood.  The  middle 
sacral  gives  one  or  two  small  branches  to  the  muscular  wall,  some  of  which 
may  penetrate  to  the  mucosa. 

A  plexus,  the  hamorrhoiddl  plexus,  is  formed  in  the  submucous  tissue 
by  the  anastomosis  of  the  branches  of  all  these  arteries. 

Veins. — The  veins  are  valveless.  In  each  column  of  Morgagni  is  found 
a  plexiform  arrangement  of  veins,  some  of  which  may  show  dilatations. 
Leaving  the  upper  end  of  each  column  are  one  or  more  veins  which,  after 
passing  a  variable  distance  in  the  submucosa,  perforate  the  muscular  wail 
and  join  the  superior  hemorrhoidal  vessels.  When  in  the  submucosa  the 
veins  freely  communicate  with  one  another,  forming  the  internal  venous 
hoBmorrhoidal  pi 

In  the  perianal  skin  are  a  number  of  radially  arranged  veins,  communi- 
cating with  one  another  by  a  circular  vein.  These  connect  above  with  the 
radicles  of  the  superior  hemorrhoidal  veins  in  the  columns  of  Morgagni.  The 
veins  of  the  anal  margin  and  the  anal  canal  chiefly  contribute  to  the  forma- 
tion of  the  inferior  hemorrhoidal  veins.  Veins  accompanying  the  middle 
hemorrhoidal  arteries  are  also  present.  On  the  outer  surface  of  the  rectal 
wall  is  a  rich  venous  plexus  contributed  to  by  all  the  veins  which  pass  out 
from  the  mucosa  through  the  bowel  wall,  and  hence  all  the  hemorrhoidal 
veins   are   brought    freely   into   communication   with  one   another.      A   free 


664  RECTUM  AND   ANAL   CANAL 

anastomosis  is  established,  therefore,  between  the  portal  and  the  systemic 
venous  circulations. 

Lymphatics, — These,  playing  such  an  important  part  in  cancer,  are 
best  considered  in  connexion  with  that  disease  (p.  717). 

Anamnesis  and  examination. — Methodical  inquiry  should 
be  made  into  the  history  of  pain,  hemorrhage,  discharge,  frequency  of 
boivel  action,  the  shape  and  size  of  the  motions,  and  the  presence 
of  any  swelling  at  or  near  the  anal  margin. 

Pain,  as  distinguished  from  mere  discomfort,  is  often  absent  in  rectal 
diseases  until  some  complication  arises,  but  is  usually  present  in  lesions  of 
the  anal  canal.  Pain  from  mobility  of  the  coccyx  and  pain  referred  from 
diseases  of  the  urinary  or  genital  tract  must  be  differentiated  from  that  of 
rectal  origin.  Hcemorrhage  of  rectal  origin  is  bright  red.  but  bright-red  blood 
occasionally  arises  from  diseases  higher  in  the  alimentary  tract.  Discharge 
from  the  anal  margin  is  constant,  whereas  from  the  rectum  it  is  only  voided 
in  response  to  the  desire  for  defalcation.  The  normal  frequency  of  boivel  action 
should  be  ascertained,  and  any  departure  from  this  noted.  Constipation 
causes  some  diseases,  results  from  others.  In  proctitis  and  ulceration  a 
characteristic  spurious  diarrhoea  occurs  ;  urgent  calls  to  stool,  frequently 
repeated,  especially  in  the  early  morning,  expel  little  but  flatus,  mucus,  and 
perhaps  blood  ;  the  motions  may  or  may  not  be  faecal-stained,  or  may  even 
contain  some  faeces.  After  expulsion  of  all  secretion  from  the  inflamed  surface 
several  hours  of  comparative  comfort  may  ensue.  The  shape  of  the  motion 
is  determined  by  the  last  orifice  through  which  it  passes,  i.e.  the  anus  ; 
therefore  narrowing  of  the  lumen  of  the  bowel  does  not  alter  the  shape  of 
the  motion  unless  the  anal  sphincteric  power  is  destroyed.  Hypertrophy  of 
the  sphincter  and  abnormal,  spasmodic  action,  which  occur  in  some  diseases 
of  the  anal  margin,  may  flatten  the  motion  or  give  it  a  tapering  extremity. 
In  stricture  of  the  bowel,  simple  or  malignant,  the  typical  motion  consists 
of  small  isolated  fragments. 

Though  a  carefully  obtained  history  will  often  suggest  the  correct  diagnosis, 
visual  examination  of  the  perineum  is  always,  and  digital  examination  of  the 
rectum  usually,  necessary.  For  the  latter,  the  well-lubricated  finger  should 
be  inserted  very  gently  and  slowly,  pressure  being  made  away  from  any 
painful  condition  of  the  anal  margin.  The  diagnosis  of  many  rectal  and 
anal  diseases  is  possible  without  further  examination,  but  visual  inspection 
of  the  interior  of  the  bowel  is  sometimes  necessary.  A  duckbill  speculum 
permits  efficient  inspection  of  the  anal  canal  and  lower  rectum  ;  for  the 
upper  rectum  the  sigmoidoscope  is  necessary* 

The  sigmoidoscope  (Fig.  482)  consists  essentially  of  a  metal  cylindrical 
tube  fitted  with  an  obturator  to  facilitate  its  introduction,  and  graduated 
on  its  exterior  to  indicate  the  distance  passed  into  the  bowel.  When  the 
obturator  is  withdrawn  a  long  rod  carrying  a  light  at  its  distal  end  is  intro- 
duced into  the  tube.  The  proximal  end  of  the  rod  fits  into  the  tube  by  a 
metal  collar  carrying  the  electric  terminals,  and  closed  by  a  glass  window 
fitted  in  a  metal  rim.  A  small  hand-bellows  at  Inched  to  the  proximal  end 
of  the  tube  permits  inflation  of  the  rectum  during  examination. 

The  instrument,  warmed  and  well  lubricated,  may  be  introduced  with 
or  without  anaesthesia.  In  nervous  patients,  or  those  with  painful  affections, 
an  anaesthetic  is  necessary.  The  bowels  must  be  previously  thoroughly 
emptied  by  aperients  and  enemata.  If  blood,  discharge,  or  faeces  obscure 
the  view,  they  may  be  removed  by  cotton-wool  pledgets  on  the  applicator. 


THE   SIGMOIDOSCOPE 


bt>5 


The  introduction  of  the  sigmoidoscope,   and   the   Interpretation  of  the 
picture  seen,  require  practice.     Houston's  valves  maj  offei  some  impediment 

to  its  passage,  init  this  is  easily  overcome  by  b  little  manipulation;  their 
appearance  is  too  characteristic  to  cause  confusion  with  a  pathological  con- 
dition. A  little  practice  is  required  to  facilitate  the  passage  ol  the  instrument 
along  the  sacrococcygeal  curve.  Any  stricture,  simple  or  malignant,  or 
any  tumour  pressing  upon  the  bowel  will  naturally  cause  some  impediment 
to  the  passage  of  the  tube.  The  correct  interpretation  of  the  appearance 
observed  requires  experience,  and  implies  sigmoidoscope  familiarity  with 
the  normal  rectum. 

The  sigmoidoscope  affords  in  valuable  diagnostic  aid  in  rectal  lesions  -ituated 
beyond  the  reach  of  the  finger.    It  is  invaluable  also  in  the  diagnosis  of  ulcer- 


Fig.  482. — The  sigmoidoscope. 

a,   The  inet.il  graduated  tube  with  hand-bellows  attached  ;  B,  the  obturator  ;  c,  the  rod  carrying 
the  light  at  the  distal  end  and  the  terminals  at  the  proximal  end;  D,  the  applicator. 

ations,  high-lying  polypi,  and  malignant  disease  of  the  upper  rectum.  When 
it  is  used  in  cases  of  ulceration  great  care  must  be  exercised  to  avoid  perfora- 
tion of  the  diseased  bowel  wall. 

MALFORMATIONS 

It  is  impossible  in  the  very  early  human  embryo  to  differentiate  the 
allantois  and  the  hind-gut.  but  as  the  hind-end  of  the  embryo  growls,  the 
body-stalk,  originally  attached  at  the  hind-end,  becomes  more  ventral,  as  also 
does  the  termination  of  the  allantois,  so  that  a  U-shaped  bend,  the  hind- 
gut,  is  formed  in  the  dorsal  part  of  the  tube.  At  tins  stage,  therefore,  there 
is  a  common  chamber,  the  cloaca,  into  which  open  the  hind-gut  and  the 
allantois.  The  opening  of  the  hind-gut  into  the  cloaca  disappears  early.  As 
the  hind-end  of  the  embryo  grows  backwards,  the  dorsal  part  grows  more 
rapidly    than    the  ventral,    and   carries   with   it    the   hind-gut    beyond  the 


666  RECTUM   AND   ANAL    CANAL 

allantois.  the  posiaUantoic  gut,  a  new  formation  entirely  separated  from 
the  cloaca,  but  without  an  external  opening  at  this  stage.  At  the  site  of 
the  future  perineum,  ventral  to  the  termination  of  the  postallantoic  gut.  the 
epiblast  becomes  thickened,  constituting  the  anal  -plug.  This  thickening  soon 
breaks  down,  and  the  anal  pit  or  proctodeum  is  formed.  The  proctodeum 
meets  the  termination  of  the  postallantoic  gut  towards  its  ventral  surface, 
the  two  being  separated  by  a  thin  membrane,  which  later  disappears. 
The  very  short  portion  of  the  postallantoic  gut  dorsal  and  posterior  to 
its  fusion  with  the  proctodeum  disappears. 

The  cloaca  forms  no  part  of  the  rectum,  but  early  becomes  separated 
from  it.  The  cloaca,  receiving  the  openings  of  the  genital  ducts,  becomes, 
in  the  male,  the  trigone  of  the  bladder  and  the  urethra  to  just  below  the 
openings  of  the  genital  ducts,  that  is,  to  just  beyond  the  verumontanum. 
In  the  female,  the  Miillerian  ducts  open  into  the  cloaca  between  the  allantois 
anteriorly,  and  the  original  aperture  of  the  hind-gut  posteriorly.  Later,  the 
ducts  migrate  to  the  posterior  part  of  the  body,  and  their  communications 
with  the  cloaca  become  lost.  The  vagina  is  for  a  great  part  of  foetal  life  a  solid 
structure  and  not  a  canal,  but  later  the  Miillerian  ducts  tunnel  a  passage 
through  this  to  the  hind-end  of  the  embryo.  The  cloaca  becomes  the  trigone 
of  the  bladder,  the  urethra,  and  the  space  between  the  labia  minora. 

Thus  the  rectum  and  anal  canal  consist  of  three  developmental  portions — 
(1)  the  hind-gut,  (2)  the  postallantoic  gut,  and  (3)  the  proctodeum.  The 
posterior  limit  of  the  body  cavity  serves  to  mark  the  junction  of  the  hind-gut 
and  the  postallantoic  gut.  This  point  in  the  fully  developed  body  is  at  the 
reflexion  of  the  peritoneum  from  the  rectum  to  the  bladder  or  the  vagina. 
The  posterior  limit  of  the  postallantoic  gut  is  the  level  of  the  anal  sinuses. 
The  proctodeum  forms  the  anal  canal  below  this  level.1 

Keith  explains  the  abnormalities  by  comparative  anatomy  and  physiology. 
"  Above  all."  he  says.  "  the  process  of  impregnation  has  to  be  kept  in  mind. 
fur  it  was  by  the  evolution  of  the  penis  that  the  rectum  attained  an  opening 
on  the  perineum.''  The  cloaca  of  the  frog  is  represented  in  the  mammal  by 
the  trigone  of  the  bladder  and  the  urethra  ;  it  is  a  passage  that  conveys  the 
urine,  genital  products,  and  feces  to  their  destination.  The  feces  have  no 
lodgment  there.  The  rectum  opens  higher  up  than  the  urinary  and  genital 
ducts.  Rarely  in  the  human  subject  does  the  rectum  open  into  the  trigone 
of  the  bladder,  and  this  exactly  reproduces  the  amphibian  form.  In  the 
tortoise  and  turtle  the  rectal  orifice  has  moved  along  the  dorsal  wall  of  the 
cloaca  nearer  the  tail  than  the  genital  and  urinary  ducts,  i.e.  exactly  in  the 
position  where  the  abnormal  rectum  commonlv  ends  in  the  human  subject, 
in  the  urethra  just  beyond  the  verumontanum.  The  termination  of  the 
rectum  as  a  fibrous  cord  on  the  base  of  the  prostate  represents  a  stage  of 
arrest  in  passing  from  the  amphibian  to  the  tortoise  form.  In  the  tortoise 
and  turtle  the  cloaca  is  becoming  modified  for  sexual  purposes,  and  is  less 
capable  of  serving  as  a  fecal  passage,  and  hence  its  orifice  has  moved  nearer 
to  the  perineum.  In  Monotrernes  the  sexual  modifications  are  carried  further, 
the  rectum  opening  into  that  part  of  the  cloaca  derived  from  the  ingrowth 
of  ectoderm,  the  endodermal  cloaca  becoming  the  urino-genital  sinus.  During 
the  evolution  of  the  higher  vertebrates  the  anus  has  migrated  from  an 
intracloacal  to  an  extracloacal  or  perineal  position.  The  various  forms  of 
malformation  represent  arrested  stages  of  migration. 

According  to  Keith,  both  the  external  and  internal  sphincter  muscles  are 

1  This  description  follows  that  which  is  given  by  F.  Wood  Jones,  and  is  the 
only  one  which  will  satisfactorily  explain  the  various  malformations. 


MALFORMATIONS   OF    RECTUM 


developed  from  the  proctodeum,  which  would,  therefore,  form  thi 
canal  as  far  as  the  upper  limit  of  the  columns  of  Morgagni.  \\  od  Jones, 
however,  considers  thai  the  anal  Binuses  limit  the  perinea]  invagination. 
Whether  the  sphincter  muscles  are  developed  in  the  absence  of  the  proctodeum 
appears  not  to  have  been  determined.  In  two  cases  where  the  rectum  ended 
blindly  at  the  base  of  the  prostate  and  the  proctodaeal  invagination  was  not 
developed,  but  the  site  of  the  anus  merely  marked  by  a  little  cutaneous 
eminence,  J  found  a  few  muscle  fibres  in  the  position  and  having  the 
oourse  of  the  external  sphincter.  There  was  certainly  no  development  of  the 
internal  Bphincter.  If  the  external  sphincter  were  developed  in  Buch 
operation  might  be  undertaken  with- some  prospect  of  success;  but  if  it  were 
not  developed,  however  brilliant  the  first  result-  of  the  operation  might 
appear,  then-  could  be  no  possibility  of  control. 

Malformations    are    conveniently    classified    according    to    Wood- 
Jones's  account  of  the  development  as  follows: — 

1.  Persistence  of  the  Original  Communication  witb  the  Cloaca 

i.  Males. — The  common  abnormality  is  the  ending  of  the  rectum 
in  the  urethra  at  the  lower  cud  of  the  verumontanum,  immediately 


Fig.  483. 


Fig.    4S4. 


Fig.   4     ■     Rectum  opening    into    the    urethra    immediately  below  the    uterus   masculinus, 

represented  bv  a  .-.light  deprosion  in  the  floor  of  the  urethra. 
I  ig.    j    ..     -Rectum  opening   into  the   navicular  fossa  of  the  vulval  cleft. 

beyond  the  openings  of  the  uterus  masculinus  and  the  vasa  deferentia 
(Fig.  483).  The  opening  is  too  small  to  allow  the  passage  of  faeces  ; 
it  seems  to  be  provided  with  a  Bphincter.  The  opening  has  been  seen 
in  the  trigone  of  the  bladder  (amphibian  form),  at  the  internal  meatus, 
and  at  the  apex  of  the  prostate. 

Cases  are  also  recorded  in  which  the  rectum  opened  into  the  frsonum 
of  the  prepuce,  the  under  surface  of  the  penis,  the  raphe  of  the  scrotum 
or  the  perineum.  According  to  Keith,  "  it  occasionally  happens  that 
not  only  is  the  perineal  orifice  of  the  cloaca  carried  forwards  on  the 
outgrowing  penis,  but  the  rectal  orifice  is  also  transplanted  with  it." 


668 


RLCTUM   AND   ANAL   CANAL 


One  specimen  in  the  Royal  College  of  Surgeons  Museum  is  unique 
(Keith)  in  that  the  rectum  has  two  openings — (a)  the  proctodeum 
has  grown  in  and  opened  into  the  rectum,  forming  an  anus  in  the 
usual  position,  and  (h)  the  cloacal  orifice  has  been  prolonged  for- 
wards, and  opens  into  the  median  raphe  of  the  scrotum  near  the  root 
of  the   penis. 

ii.  Females. — The  commonest  abnormality  is  where  the  rectum 
opens  into  the  navicular  fossa  of  the  vulval  cleft  (Fio-.  484),  that  is,  in 
a  position  corresponding  to  the  abnormal  opening  in  the  male  subject. 
Some  reports  state  that  a  sphincter  exists  at  the  opening. 

The  rectum  has  been  seen  opening  into  the  vagina.  Such  cases, 
according  to  Keith's  observations,  are  associated  with  a  divided  vagina, 
the  arrested  rectum  probably  preventing  the  fusion  of  the  Mullerian 
ducts  to  form  the  vagina.     In  a  few  cases  the  vulva  and  clitoris  are 


Fig.  485.  —  Rectum  ending 
blindly  at  the  back  of  the 
prostate  gland. 


Fig.  486. — Rectum  ending  blindly 
at  the  upper  level  of  the  pos- 
terior fornix  of  the  vagina. 


prolonged  to  form  a  urethra,  and  the  rectum  has  been  seen  orjening 
in  the  floor  of  this  urethra  immediately  below  the  orifice. 


2.  Non-Development  or  Imperfect  Development  of  the 
postallantoic  gut 

i.  The  postallantoic  gut  may  be  practically  non-existent,  the 
rectum  ending  blindly  at  the  base  of  the  prostate  (Fi.fr.  485)  or  at 
the  upper  level  of  the  vagina  (Fig.  486).  A  fibrous  cord  may  attach 
the  termination  of  the  rectum  to  these  viscera  (Figs.  487  and  4S8). 

ii.  The  postallantoic  gut  may  grow  backwards  imperfectly,  becom- 
ing separated  from  the  prostate  or  the  vagina  (Fig.  489).  It  may  end 
as  a  fibrous  cord  attached  either  to  the  proetodeal  invagination  (Fig. 
490),  or,  if  this  be  not  developed,  to  the  site  of  the  normal  anus. 


MALFORMATIONS   OF    RECTUM 


669 


3.  Non-Development  or  [ll-Developmkxt  at-  mi;  h od.eu.m 

The  proctodaeum  and   the  postallantoic   gul    may  themselves  In- 
well  formed,  bul  the  original  membrane  separating  them  may  partially 


Fig.  487- — Blind  end  of  rectum 
attached  to  the  prostate  by 
a  fibrous  cord. 


Fig.  4SS. — Blind  end  of  rectum 
attached  by  a  fibrous  cord  to 
the  posterior  vaginal  vault. 


or  completely  persist  ;    in  the  former  case  a  fibrous  stricture,  in  the 
latter  an  absolute  barrier,  results  (Fig.  491). 

The  proctodeum  may  be  very  feebly  developed,  or  there  may  be 


Fig.  4S9. — Postallantoic  gut 
separated  from  the  prostate 
and  ending  blindly  at  some 
distance  from  the  peri- 
neum ;  there  is  no  develop- 
ment of  the  proctodaeum. 


Fig.  490. — Postallantoic  gut 
attached  to  the  proctodaeum 
by  a  fibrous  cord  ;  both  the 
postallantoic  gut  and  the 
proctodaeum  are  imperfectly 
developed. 


no  depression  at  all.    In  some  cases  there  is  nothing  to  mark  the  site 
of  the  normal  anus ;    in  others  there  is  an  eminence  at  this  site. 
The  condition  of  development  of  the  proctodaeum  is  no  measure 


()/0 


RECTUM   AND   ANAL    CANAL 


of  the  degree  of  development  of  the  rectum.  Usually,  when  the 
rectum  ends  in  the  vulva  the  proctodeum  is  absent.  When  the  rectum 
ends  in  the  prostatic  urethra  the  proctodseum,  as  a  rule,  is  absent  or 
imperfectly  developed.  Generally  speaking,  the  nearer  the  rectum 
is  to  the  perineum  the  better  developed  is  the  proctodseum,  but  to  this 
there  are  many  exceptions.  Conversely,  if  a  well-developed  proctodseum 
be  present,  it  does  not  always  follow  that  the  rectum  is  well  developed. 

The  symptoms  depend  upon  the  type  of  deformity  present. 
When  a  narrowing  at  the  junction  of  the  postallantoic  gut  and  procto- 
dseum only  is  present,  the  severity  of 
obstruction  will  depend  upon  the 
tightness  of  the  stricture.  The  stric- 
ture may  be  very  slight,  and  symp- 
toms may  be  practically  absent  ;  on 
the  other  hand,  obstinate  constipation 
and  abdominal  distension  may  be  pre- 
sent. Symptoms  may  be  delayed  for 
some  time  after  birth  in  this  variety. 

When  there  is  no  outlet  for  the 
meconium,  abdominal  distension  and 
vomiting  will  be  present  soon  after 
birth.  Rapid  wasting  occurs,  and,  if 
the  condition  be  not  relieved  within  a 
few  days,  death  ensues. 

When  the  rectum  opens  into  the 
vulva  the  opening  is  often  sufficient 
to  allow  the  passage  of  meconium.  Adult  age  has  been  reached 
with  this  deformity,  sometimes  with  very  little  inconvenience,  except 
constipation  or  recurrent  attacks  of  subacute  intestinal  obstruction 
relieved  by  aperients. 

When  the  rectum  opens  into  the  urethra  the  outlook  is  far  less 
favourable,  for  the  opening  is  rarely  large  enough  to  transmit  the 
fseces,  and  symptoms  of  intestinal  obstruction  in  various  degrees  are 
soon  evident,  In  a  few  cases,  however,  life  has  been  prolonged  for 
three  or  four  years,  but  rarely  longer. 

Treatment. — This  may  be  considered  with  reference  to  (1) 
those  cases  in  which  the  intestinal  canal  ends  blindly  and  there  is 
no  outlet  for  its  contents,  and  (2)  those  in  which  there  is  an  outlet 
in  an  abnormal  situation. 

1.  Immediate  relief  is  necessary,  failing  which  death  will  occur 
within  a  few  days.  The  deformity  is  often  overlooked  through  care- 
lessness for  the  first  day  or  so  of  the  infant's  life,  and  recognized  only 
when  symptoms  of  intestinal  obstruction  appear.     When  relief  has 


Fig.  491.  —  Postallantoic  gut 
and  proctodeum  fully  de- 
veloped, but  the  two  cavities 
separated  by  a  thin  mem- 
brane. 


MALFORMATIONS  OF    RECTUM:    TREATMENT    671 

been  given  by  the  simples!  method,  a  considerable  proportion  01  the 
infants  will  die,  even  when  operation  is  undertaken  early. 

i.  T/>r  deformity  consists  of  a  membrane  of.  varying  thic) 
between  the  proctodoBum  and  the  rectum.  The  proctodeum  ia  well 
developed,  and  .1  marked  bulging  of  the  rectum  into  it  will  be 
fell  when  the  infanl  strains.  All  thai  is  necessary  lb  to  incise  t  }h- 
membrane  and  remove  aa  much  of  it  as  possible.  Some  degree  ol 
congenita]  narrowing  of  the  Lumen  of  the  bowel  may  be  present  a1 
the  site  of  attachmenl  of  the  membrane  to  the  bowel  wall.  Thia 
must  lif  overcome  by  the  Erequenl  passage  of  a  finger  or  the  bougie. 

ii.  Thi-  proctodoBum  may  or  may  not  be  developed,  and  there 
u  /"<  evidence  (<>  show  the  degree  of  development  of  the  rectum. 
— Two  methods  of  procedure  are  possible — (a)  immediate  colostomy, 
and  some  weeks  or  months  later  the  establishment  of  an  anus 
in  a  normal  position,  or  (b)  an  immediate  attempt  to  form  an 
anus  in  the  normal  position  by  a  perineal  dissection.  In  deciding 
between  these  alternatives  it  must  be  remembered  that  the  degree 
of  development  of  the  proetodseum  is  not  proportional  to  that  of  the 
development  of  the  rectum,  which,  with  a  well-developed  proctodanim, 
may  be  found  as  high  as  the  base  of  the  prostate  or  the  vagina  ;  that 
the  only  permissible  method  of  forming  the  anus  in  the  perineum  is 
freely  to  separate  the  rectum  from  its  connexions,  and  draw  it  to  the 
anal  margin,  or  the  skin  of  the  future  anus,  without  tension — a  dissection 
which,  if  the  rectum  ends  high,  will  be  very  difficult  to  execute  in  an 
infant  two  or  three  days  old  suffering  from  intestinal  obstruction,  and 
will  very  probably  be  fatal ;  that  the  mere  exposure  and  opening  of 
the  rectum,  allowing  the  contents  to  escape  through  the  track  thus 
made,  will  only  be  followed  by  irremediable  stricture,  which  of  itself 
will  sooner  or  later  prove  fatal ;  that  the  most  rapid  method  of  giving 
relief  should  be  chosen  ;  and  that  the  immediate  results  of  colostomy 
are  superior  to  those  of  a  primary  perineal  anus.  As  a  general  rule. 
therefore,  it  is  best  to  perform  colostomy.  This  should  be  done  through 
as  small  an  incision  as  possible  in  the  left  iliac  region.  The  excoriation 
of  the  skin  which  will  occur  around  the  opening,  may,  with  care,  be 
kept  well  under  control,  and  is  probably  no  worse  than  that  which 
occurs  in  the  perineum  when  an  anus  is  made  there. 

Later,  at  a  time  which  will  vary  with  the  condition  of  the  child's 
health,  an  attempt  is  made  to  form  a  perineal  anus.  It  may  be  necessary, 
if  the  postallantoic  gut  be  absent,  to  remove  the  coccyx.  Any  muscle 
fibres  should  be  carefully  preserved.  The  rectum  must  be  separated 
from  its  surroundings  (which  will  often  mean  a  free  opening  of  the 
peritoneal  cavity),  and  so  mobilized  that  it  may  be  sutured  to  the  skin 
of  the  perineum  without  tension.  Later  the  colostomy  is  closed.  This 
operation,  if  the  rectum  is  low  in  the  perineum  and  the  proctodavurn 


RECTUM    AND    ANAL    CANAL 

(with  the  sphincters)  is  developed,  may  give  a  good  result.  If, 
on  the  other  hand.,  the  rectum  lies  high,  the  operation  will  be  severe 
and  the  prognosis  grave.  When  recovery  ensues,  three  accidents  may 
befall  the        .  A  stricture  may  occur:    this  will  not  happen  if 

the  bowel,  which  has  been  brought  well  down,  and  sutured  to  the  skin, 
does  not  later  recede.  A  stricture  has  probably  always  resulted  in 
those  -re  the  bowel  has  been  blindly  opened  at  some  depth 

in  the  perineum,  and  a  fistulous  track  established  between  the  bowel 
and  the  perineum.  This  is  not  an  anus,  (b)  There  may  be  deficient 
sphincter  i<  control  of  the  new  anus.  If  the  proctodeum  is  developed, 
and  care  has  been  taken  to  preserve  the  sphincters,  then  control  may 
be  obtained  ;  but  in  the  absence  of  development  of  the  proctodaeum 
the  internal  sphincter  is  absent,  and  probably  the  external,  if  developed 
at  all,  is  very  poor,  and  there  will  be  no  control,  (c)  In  some  cases 
prolapse  of  the  mucous  membrane  has  occurred.  This  is  likely  to 
happen  when  there  is  no  Bphincteric  closure  of  the  anus. 

2.  The  treatment  of  this  group  may  differ  with  the  sex  of  the 
patient  and  with  the  severity  of  symptoms.  In  the  female  the  opening 
in  the  vulval  cleft  is  frequently  of  sufficient  size  to  allow  the  escape 
of  the  intestinal  contents,  it  is  provided  with  a  sphincter,  and  the 
proctodaeum  is  very  frequently  absent.  It  would  therefore  seem  best 
to  leave  things  alone.  Transplanting  the  anus  from  the  vulva  to  the 
perineum  would  merely  substitute  an  anus  in  the  normal  position 
without  control  for  the  one  in  the  abnormal  position  with  control. 
If,  however,  the  aperture  is  too  small,  an  anus  should  be  made  in  the 
normal  site. 

In  the  male  the  condition  is  different,  for  the  aperture  is  nearly 

always  too  small,  and  some  relief   from  obstruction  is  required.      If 

this  is  not  necessary  in  early  infancy  it  will  become  so  later.    In  such 

the  urgency  of  symptoms  and  age  of  the  child  will  decide  whether 

a  primary  colostomy  or  a  perineal  dissection  should  be  performed. 

HEMORRHOIDS,   OR    PILES 

This  term  includes  a  variety  of  conditions  dependent  primarilv. 
in  the  majorir  «,  upon  a  varicosity  of  the  veins  of  the  lower 

rectum  and  anal  canal. 

Etiology. — The  condition  is  most  common  in  middle  life,  and 
affects  both  sexes  equally.  Although  not  unknown,  it  is  very  rare  in 
childhood  ;  indeed,  an  instance  of  congenital  piles  is  recorded.  It 
appears  to  be  certain  that  there  is  an  hereditary  predisposition. 

hanical  congestion  of  the  rectal  veins  is  the  exciting  cause, 
and  habitual  constipation  one  of  the  most  important  etiological  factors. 
During  normal  defaecation  temporary  dilatation  of  the  valveless  lower 
rectal  and  anal  veins  is  encouraged  by  (1)  the  passage  of  faeces  through 


HEMORRHOIDS  673 

the  rectum  exerting  pressure  in  a  direction  reverse  to  that  of  the  blood- 
How  in  the  ascending  veins;  (2)  the  contraction  of  the  muscular  walls 
of  the  bowel  tending  to  constrict  the  apertures  through  which  the  veins 
pass;  (3)  the  raising  of  the  blood  pressure  in  both  the  porta]  and  cava] 

systems  during  forced  expiratory  efforts,  and  (4)  the  loss  of  support 
to  the  veins  due  to  relaxation  of  the  sphincters  and  levatores  ani.  In 
habitual  constipation,  faeces  are  more  or  less  constantly  retained  in 
the  rectum,  and,  becoming  unduly  solid  from  absorption  of  water, 
cause  constant  pressure  on  the  ascending  veins.  The  contraction  of 
the  rectal  wall  is  increased  in  force,  and  expulsive  expiratory  efforts 
are  prolonged.  Ultimately,  the  repeated  and  severe  venous  distension 
so  induced  terminates  in  permanent  varicosity. 

Other  forms  of  mechanical  venous  obstruction,  acting  alone  or 
in  combination  with  constipation,  are  sometimes  responsible  for  piles. 
The  condition  may  be  associated  with  local  pressure  by  the  gravid 
uterus  or  pelvic  tumours,  with  the  general  back  pressure  of  cardiac 
and  pulmonary  diseases,  and  with  the  portal  obstruction  of  hepatic 
cirrhosis,  or  of  hepatic  congestion  in  those  who  habitually  eat  and 
drink  to  excess. 

In  some  cases  local  irritation  seems  to  produce  or  to  aggravate 
haemorrhoids ;  thus,  etiological  association  has  been  claimed  with 
worms  in  children,  and  with  fissures,  ulcerations,  and  fistulse,  and 
even  with  diarrhoea  ;  while  the  mechanical  results  of  rectal  accumu- 
lations of  faeces  may  be  aided  by  their  irritant  effects. 

Classification. — Anatomically,  piles  are  divided  into  external 
and  internal.  In  the  former  the  tumour  is  covered  with  skin,  and  in 
the  latter  with  mucous  membrane.  This  is  also  a  useful  clinical  classi- 
fication, since  the  symptoms,  complications,  and  treatment  differ. 

External  Piles 

-  ral  different  conditions  are  included,  some  only  of  which  satisfy 
the  definition. 

1.  Dilatation  of  the  Anal  Veins 

The  veins  surrounding  the  anal  margin  are  dilated,  and  during 
straining  form  a  distinct  swelling ;  when  straining  ceases  the  veins- 
subside,  leaving  the  skin  loose.  The  condition  is  always  associated 
with  constipation,  and  is  frequently  accompanied  by  internal  piles. 

The  symptoms  are  merely  a  feeling  of  fullness  and  uneasiness 
after  defalcation.  Spasmodic  contraction  of  the  sphincter  may  occur, 
and  in  time  the  muscle  may  become  hypertrophied. 

Treatment  should  be  directed  to  inducing  regular    action  of 
the  bowels.      In  some  cases  where  the  sphincter  is  markedly  hyper- 
trophied its  division  may  give  relief. 
2r 


674  RECTUM   AND   ANAL    CANAL 

2.  The  Thrombotic  Pile 

This  term  does  not  always  indicate  the  true  pathology.  It  implies 
the  formation  of  a  thrombus  in  one  of  the  anal  veins.  This  may  occur 
in  a  few  cases,  but  more  commonly  the  prime  condition  is  a  rupture  of 
a  vein.  The  usual  history  is  that  more  or  less  suddenly,  and  generally 
during  some  straining  effort,  there  appears  at  the  anal  margin  a  swelling 
which  consists  of  extravasated  blood,  fluid,  tense  and  cystic  at  first, 
but  later  clotted  and  more  firm.  Should  the  swelling  be  a  primary 
intravenous  thrombosis,  it  is  comparatively  smaller  and  not  cystic. 
Although  generally  single,  occasionally  more  than  one  swelling  may 
form.  The  tumour  is  tender  and  painful,  especially  during  defalcation, 
which  is  therefore  postponed  as  long  as  possible.  Walking  aggravates 
the  pain,  and  sitting  may  be  impossible. 

The  terminations  are  :  (1)  Resolution.  This  may  occur  if  the  swelling 
is  small,  and  irritation  and  constipation  are  prevented.  Some  three 
or  four  weeks  are  required  before  the  blood  is  completely  absorbed. 
(2)  Suppuration.  The  clot  becomes  infected  with  pyogenetic  organisms, 
and  an  anal  abscess  results  (p.  684).  (3)  The  clot  is  incompletely  absorbed, 
being  transformed  into  fibrous  tissue.  A  variety  of  cutaneous  pile  is 
thus  formed  (see  below).  (4)  Rarely  the  skin  gives  way,  the  clot  is 
extruded,  and  a  natural  cure  results. 

The  treatment  is  at  first  symptomatic.  Daily  easy  action  of 
the  bowels  should  be  ensured  by  a  mild  aperient.  Pain  should  be 
relieved  by  the  application  of  lead  lotion,  or  sometimes  hot  moist 
applications  are  more  gratifying.  Xo  further  treatment  is  required 
in  most  cases.  Should,  however,  the  swelling  show  no  sign  of  diminish- 
ing in  a  few  days,  the  overlying  skin  should  be  anaesthetized  with 
eucaine,  and  incised  in  a  direction  radiating  from  the  anal  margin. 
The  clot  should  be  expressed,  and  the  cavity  allowed  to  heal  from  the 
bottom. 

The  condition  is  liable  to  recur,  therefore  straining  efforts  and 
constipation  are  to  be  avoided. 

3.  Cutaneous  Piles  or  Redundant  Folds  of  Perianal  Skin 
In  appearance  the  folds  are  an  exaggeration  of  those  normally 
present  around  the  anal  margin.     In  structure  there  is  an  increase 
of  connective  tissue ;  there  is  also  in  some  cases  a  dilatation  of  the 
anal  veins,  but  this  is  by  no  means  constant. 

Etiology. — As  indicated  above,  the  cutaneous  pile  may  arise 
from  the  thrombotic  one,  either  by  the  organization  of  the  clot  or 
by  increase  in  the  surrounding  tissues  due  to  the  irritation  caused 
by  it.  In  other  cases  constipation  is  the  prime  factor.  Excoriation 
of  the  skin  of  the  anal  margin  by  the  passage  of  hard  faecal  masses 
leads    to    a    mild   infection,   and   therefore  to    some    cedema    of   the 


HEMORRHOIDS  675 

normal  ruga1 ;  the  recurrence  «>f  this  process  Induces  chronic  inflam- 
matory tissue  change,  and  therefore  the  formation  of  redundant 
folds.  Should  the  perianal  veins  be  also  dilated,  thee  will  tend  to 
increase  the  size  of  the  folds.  The  enlargement  <>f  the  perianal  fold- 
hinders  the  proper  cleansing  of  the  skin  after  defalcation,  and  there- 
fore predisposes  to  additional  excoriation  of  the  skin  in  the  crevii 
from  which  a  further  infection  or  even  a  true  fissure  may  arise. 
Hence  the  condition,  when  once  established,  is  always  liable  to 
become  aggravated. 

Symptoms. — A  mere  redundancy  of  the  perianal  folds  gives  rise 
to  few  symptoms.  The  repeated  attacks  of  inflammation  are  accom- 
panied by  pain,  especially  during  defsecation,  and  hence  the  patient 
refrains  from  the  act  as  long  as  possible.  Difficulty  in  thoroughly  cleans- 
ing the  parts  after  defalcation  may  cause  pruritus  ani  (p.  727),  and  the 
frequent  rubbing  to  relieve  this  symptom  will  aggravate  the  condition. 

Treatment. — The  first  care  is  to  treat  efficiently  the  constipa- 
tion. After  defalcation  the  anus  should  be  thoroughly  cleansed  with 
water,  dried,  and  then  washed  with  oil.  A  soothing  ointment  or 
powder — e.g.  bismuth  or  zinc  combined  with  starch — should  be  applied. 
Should  this  fail  to  relieve,  operative  measures  are  indicated.  A  general 
anaesthetic  is  necessary.  About  two-thirds  of  the  redundant  fold  is 
removed,  leaving  sufficient  of  the  base  to  allow  the  sides  to  fall  together. 
Each  cutaneous  pile  may  be  thus  removed  without  fear  of  stricture. 
As  in  all  operations  in  this  region,  complete  bodily  rest  should  be 
enforced  until  the  wound  has  healed,  otherwise  troublesome  fissures 
or  ulcerations  may  develop. 

4.  The  True  External  Pile 

In  this  condition  there  is  a  tumour  (rarely  more  than  one)  at  the 
anal  margin.  It  is  composed  of  dilated  veins  and  hypertrophied 
•connective  tissue,  the  result  of  repeated  irritation.  Thrombosis  may 
occur  in  the  veins. 

In  the  absence  of  acute  inflammation,  symptoms  are  slight,  and 
are  similar  to  those  of  the  foregoing  variety.  When  inflammation  is 
present,  acute  pain  and  spasmodic  contractions  of  the  external  sphincter 
render  the  condition  very  distressing.  Not  infrequently  a  fissure  may 
•develop  at  the  base  of  the  pile. 

The  treatment  in  all  cases  is  removal.  Sufficient  of  the  skin 
covering  the  base  of  each  tumour  should  be  retained  to  allow  the 
sides  to  fall  together  so  that  undue  contraction  may  be  avoided. 

Internal  Piles 

These  consist  primarily  of  a  dilatation  of  the  radicles  of  the  supe- 
rior haemorrkoidal  vein,  and  secor  iarily  of  connective-tissue  increase  in 


6;6 


RECTUM  AND   ANAL   CANAL 


the  columns  of  Morgagni ;  in  the  early  stage  internal  piles  are  merely 
enlargements  of  these  columns  (Fig.  492),  and  appear  as  longitudinal 
sessile  folds  of  mucous  membrane.  Later  they  increase  and  become  more 
globular,  or  rarely  pedunculated.  Entering  the  upper  level  of  the 
tumour  is  an  artery,  the  terminal  branch  of  the  superior  hsemorrhoidal 
artery.  Occasionally,  several  arteries  enter  the  pile,  the  latter  being 
then  so  vascular  as  to  deserve  the  name  arterial  pile.  Sometimes,  as 
the  result  of  periphlebitis,  the  blood  in  the  dilated  veins  coagulates, 
and  organization  of  the  clot  may  occur,  with  the  result  that  the  pile 
is  reduced  to  a  small  fibrous  mass. 


Fig.  492. — Lower  rectum  and  anal  canal  opened  vertically, 
and  the  edges  held  widely  apart.       From  a  preparation. 

M.,  column  of  Morgagni  ;  s.,  sinus  of  Morgagni  ;  v.,  anal  valve  ;  i.h..  internal  hemorrhoids,  in 
the  early  stage,  showing  the  pile  to  be  an  enlargement  of  the  column  of  Morgagni. 

Symptoms.— Some  discomfort  and  a  feeling  of  incomplete  empty- 
ing ot  the  bowel  may  be  experienced,  but  true  pain  is  not  present 
unless  some  complication  occurs.  Bleeding  is  the  common  symptom. 
At  first  it  happens  only  during  defalcation,  either  at  every  act,  or 
it  may  be  at  intervals  of  days,  weeks,  or  months.  Later,  haemorrhage 
may  occur  at  other  times,  e.g.  during  active  exercise.  The  amount 
of  blood  lost  varies  between  a  few  drops  only  at  the  end  of  defalcation 
and  a  continuous  loss  sufficient  to  induce  grave  anaemia  in  a  few  weeks. 
The  source  of  the  blood  is  an  abrasion  on  the  mucosa. 

As  internal  haemorrhoids  increase  in  size  they  tend  to  prolapse 
through  the  anus.  This  protrusion  differs  from  that  of  a  pedunculated 
growth  which  is  thrust  bcdily  through  the  orifice.     The  pile,  being 


1NTKRNAL    HEMORRHOIDS:   TREATMENT      677 

sessile,  when  extruded  is  accompanied  by  an  everaion  of  the  skin  of 
the  anal  canal,  giving  rise  to  the  erroneous  belief  that  external  piles 
are  also  present.  When  the  anal  canal  reverts  to  the  normal,  external 
piles,  if  present,  will  be  Been.  Interna]  piles  project  at  first  only  during 
defalcation,  retreating  when  the  act  ceases,  but  frequent  recurrence 
of  the  prolapse  relaxes  the  sphincteric  tone,  and  protrusion  may  occur 
during  any  expiratory  effort,  sudden  exertion,  or  even  walking.  The 
raucous  membrane  of  a  pile  frequently  extruded  may  become  inflamed 
and  secrete  a  mucoid  discharge  which  may  cause  pruritus  ani  (p.  727). 
Superficial  ulceration  or  even  suppuration  may  occur.  On  the  other 
hand,  a  pile  prolapsed  may  become  so  tightly  gripped  by  the  sphincter 
muscles  that  it  is  only  with  difficulty  reduced.  If  allowed  to  remain 
prolapsed,  it  will  rapidly  swell  from  interference  with  its  vascular 
circulation,  acute  infection  is  liable  to  occur,  and  this  may  be  followed 
by  ulceration,  or  gangrene  of  the  whole  or  part  of  the  pile.  If  gangrene 
occur  the  extruded  mass  may  separate  and  a  cure  result,  but  such  a 
sequel  should  only  be  permitted  in  exceptional  cases. 

The  diagnosis  of  internal  piles  should  be  easy  if  a  proper  ex- 
amination be  made  by  means  of  a  speculum  and  reflected  light.  If 
pain  be  excessive,  probably  some  complication  is  present,  e.g.  a  fissure 
or  suppuration.  Careful  examination  easily  demonstrates  that  the  pro- 
truded mass  consists  of  the  mucosa  of  the  anal  canal,  and  that  it  is 
not  derived  from  a  point  higher  in  the  bowel  as  is  a  polvp  or  an  intus- 
susception ;  moreover  the  pedicle  of  a  polyp  is  readily  felt  on  digital 
examination.  Intussusception  in  the  rectum  probably  does  not  occur 
in  the  absence  of  a  tumour. 

Treatment. — Palliative  measures  are  indicated  at  first 
in  many  cases.  They  may  suffice  where  bleeding  is  trivial,  protru- 
sion slight  or  absent,  and  the  prime  cause  of  the  piles,  e.g.  gestation  or 
a  pelvic  tumour,  has  been  removed.  In  old  age  associated  with  arterial 
degeneration,  bleeding  from  internal  piles  may  be  regarded  as  favour- 
able, tending  to  deplete  the  circulation.  In  more  than  one  such  case, 
where  piles  have  been  removed,  cerebral  haemorrhage  has  followed.  In 
cases  of  chronic  cardiac  or  pulmonary  disease,  or  portal  obstruction, 
operative  treatment  is  contra-indicated.  In  portal  obstruction,  haemor- 
rhage relieving  the  portal  circulation  tends  to  prevent  ascites"  and 
haematemesis. 

The  first  care  must  be  to  keep  the  bowels  regular  by  the  systematic 
and  judicious  administration  of  aperients.  There  is  no  one  aperient 
which  can  be  vaunted  ;  several  may  have  to  be  tried  before  the  one 
which  suits  the  patient  is  found  ;  saline  purgatives  are  generallv 
inadvisable.  Undue  hardness  of  the  motion  must  be  prevented  by  the 
injection  into  the  bowel  of  warm  olive  oil.  The  diet  must  be  regulated, 
and   especially  in  those   who   habitually   eat   and   drink   excessivelv. 


6;  S 


RECTUM   AND   ANAL   CANAL 


Alcohol  is  better  avoided.  Regular  exercise  should  be  taken.  Under 
such  treatment  many  cases  are  immensely  relieved,  as  regards  both 
bleeding  and  protrusion.  Should  bleeding  still  continue,  an  astringent 
application  should  be  employed,  e.g.  an  injection  of  a  solution  of 
sulphate  of  iron  or  adrenalin,  a  powder  such  as  dried  sulphate  of  iron, 
bismuth,  or  zinc,  a  suppository  containing  gallic  or  tannic  acid,  or 
an  ointment,  of  which  the  principal  ingredient  may  be  one  of  the  fore- 
going, or  hamamelis. 

Operative  treatment  should  be  advised  when  palliative 
measures  have  failed.  It  is  indicated  when  bleeding  is  continuous, 
when  prolapse  is  frequent,  when  there  is  a  persistent  discharge  causing 
pruritus  ani,  when  fissure  is  present,  or  when  inflammation,  sloughing 
or  gangrene  has  occurred. 

There  are  four  methods  of  operation — (1)  the  clamp  and  cautery, 
(2)  the    ligature,  (3)    the    excision  of    individual    piles,  and    (4)  the 


493. — Clamp  for  internal  haemorrhoids  preparatory  to  their 
cauterization. 

removal   of   a   complete  ring  of  mucosa,  the  so-called  "  pile-bearing 
area  "  (Whitehead's  operation). 

1.  Clamp  and  cautery. — It  is  claimed  for  this  operation  that  the 
after-pain  is  less  than  when  other  methods  are  employed,  the  convales- 
cence is  shortened,  and  there  is  no  tendency  to  a  contraction  of  the 
anal  canal.  Practical  experience  shows  that,  provided  the  cautery 
is  used  at  a  dull-ied  heat,  reactionary  haemorrhage  is  not  more  frequent 
after  this  than  after  the  other  methods.  The  method  is  better  not 
employed  when  external  piles  requiring  removal  are  also  present. 
It  is  strongly  indicated  where  the  piles  are  acutely  inflamed,  sloughing 
or  gangrenous,  for  no  foreign  body  is  left  in  the  wound. 

After  dilatation  of  the  sphincters,  each  pile  is  grasped  at  its  base 
by  a  special  clamp  (Fig.  493),  and  then  seared  off  by  the  knife  of  a 
Paquelin  cautery.  The  clamp  is  gradually  relaxed,  and  if  any  bleeding 
is  seen  the  clamp  should  be  tightened  and  the  stump  again  cauterized  ; 
this  is  repeated  until  all  bleeding  has  ceased. 

2.  Ligature. — This  is  the  method  which  has  most  advocates. 
It  may  be  employed  in  any  case,  but  is  especially  indicated  where 


INTERNAL    HEMORRHOIDS:   TREATMENT      679 

inflammation  is  absent  and  the  number  <>f  piles  La  limited.  It  should 
be  reserved  for  those  cases  in  which  the  piles  are  no1  more  than  four 
or  five  in  number,  and  form  definite  tumour  masses,  with  healthy 
mucosa  between  them.  On  the  other  hand,  where  practically  the 
whole  mucosa  is  the  seat  of  hemorrhoidal  changes,  and  where  prolapse 
is  great,  Whitehead's  operation  will  give  a  better  result. 

To  perform  the  ligature  operation  the  sphincters  are  thoroughly 
stretched  and  the  piles  allowed  to  protrude.  Each  pile  is  seized  in 
ring-forceps.  A  curved  incision  is  made  through  the  cutaneous  ring 
formed  by  the  everted  anal  canal  about  midway  between  its  outer 
margin  and  the  muco-cutaneous  junction  corresponding  to  the  base  of 


Fig.  494.  Fig,  495. 

The  operation  for  removal  of  an  internal  pile.    (See  text.) 

the  pile,  the  ends  of  the  incision  terminating  in  the  mucous  membrane 
at  the  sides  of  the  pile  (Fig.  494).  The  incision  is  deepened  through  the 
subcutaneous  tissue  to  the  external  sphincter  muscle,  which  is  recog- 
nized and  avoided  (Fig.  495).  By  continuing  the  dissection  up  the 
anal  canal  a  pedicle  containing  the  vessels  of  the  pile  is  formed.  This 
is  transfixed,  ligatured  tightly,  and  the  pile  cut  away  not  too  closely 
to  the  ligature,  for  fear  the  latter  should  slip  from  the  stump.  The 
stump  will  separate,  with  the  ligature,  in  about  ten  days'  time. 

3.  Excision  of  each  individual  haemorrhoid  is  a  modification 
of  the  ligature  operation.  The  pile  is  seized  longitudinally  by  a  long 
narrow  clamp,  and  its  upper  pole,  including  the  main  vessels,  is  trans- 
fixed and  ligatured  just  above  the  end  of  the  clamp.     The  projecting 


68o 


RECTUM  AND   ANAL   CANAL 


hemorrhoid  is  cut  off,  the  edges  of  the  mucous  membrane  sutured 
with  the  long  ends  of  the  ligature,  and  the  clamp  removed. 

4.  Whitehead's  operation  is  performed  as  follows:  An  incision 
is  made  circumferentially  through  the  skin  of  the  anal  canal  imme- 
diately outside  the  muco-cutaneous  junction  (Fig.  496).  The  incision 
is  deepened  until  the  external  sphincter  muscle  is  exposed  (Fig.  497). 
The  mucous  membrane  in  its  entirety  is  dissected  off  the  underlying 
structures  until  healthy  mucosa  above  is  reached  (Fig.  498).  The 
diseased  mucosa  is  removed,  and  the  healthy  cut  edge  is  sutured  to  the 
skin  of  the  anal  margin  (Fig.  499). 


Fig.  496.  Fig.  497. 

First  and  second  stages  of  Whitehead's  operation.    (See  text.) 

After-treatment. — Shortly  after  the  operation  a  hypodermic, 
injection  of  morphia  is  given.  The  bowels  are  confined  for  four  days. 
If  the  bowel  has  been  thoroughly  emptied  before  operation,  there  will 
be  no  difficulty  in  this  ;  should  it  be  thought  desirable,  a  catechu  and 
opium  mixture  may  be  given  for  the  purpose.  On  the  night  of  the 
third  day  an  aperient  is  administered,  and  in  order  to  soften  the 
motion,  and  so  to  lessen  pain,  some  warm  oil  is  injected  into  the 
rectum.  Just  before  the  bowels  act  some  cocaine  ointment  may  be 
applied  to  the  wound.  The  wound  must  be  kept  scrupulously  clean, 
and  particular  attention  paid  to  it  after  defecation. 

The  complications  that  may  arise  after  the  operation  are — 
(a)  Hemorrhage.- — This  occurs  either  from  the  slipping  of  a  ligature 
or  from  an  unoccluded  vessel.    It  is  evidenced  by  the  general  signs  of 


INTERNAL   HAEMORRHOIDS:   TREATMENT      68 1 

loss  of  blood,  and  the  saturated  condition  of  tin-  dressing.  It  must 
be  remembered  thai    considerable   hemorrhage   may  occur  into  the 

rectum  before  appearing  outside.  It  is  unusual,  and  is  probably  not 
more  frequent  after  one  method  of  operation  than  another.  The  treat- 
ment must  be  prompt.  The  patient  is  ansesl  hetized,  I  he  rectum  irrigated 
to  remove  all  clots,  and  examination  made  for  the  bleeding-point. 

If  this  can  be  found,  it  should  be  ligatured.  In  all  probability  bleeding 
will  have  ceased,  and  all  that  can  be  done  is  to  pass  a  tube,  to  which 
a  petticoat  of  lint  has  been  tied,  into  the  rectum,  and  to  pack  gauze 
between  the  tube  and  the  petticoat  to  prevent  a  recurrence. 


Fig.  498.  Fig.  499. 

Third  and  fourth  stages  of  Whitehead's  operation.     (See  text.) 

(b)  Infection. — Severe  sepsis  rarely  occurs,  but  occasionally,  especi- 
ally when  the  operation  is  undertaken  for  inflamed  or  sloughing  piles, 

•some  septic  infection  may  ensue  and  lead  to  troublesome  ulceration, 
which   will   increase   the   tendency  to   stricture.      Specific   infections, 

•  e.g.  tetanus  and  pyaemia,  have  been  known  to  occur,  but  they  are 

•  extremely  rare. 

(c)  (Edematous  tags  of  skin  at  the  anal  margin  are  frequently  present 
within  a  few  days  of  the  operation.  These  are  due  either  to  an  inflam- 
matory disturbance  or  to  interference  with  the  venous  circulation. 
They  occur  alike  after  the  ligature  and  the  Whitehead  operation.    In  the 

•  great  majority  of  cases,  if  the  operation  has  been  properly  performed, 
they  subside  under  the  application  of  astringent  lotions.  In  a  few 
cases,  however,  they  may  have  to  be  removed  under  local  anaesthesia. 


682  RECTUM   AND   ANAL   CANAL 

{(].)  Temporary  loss  of  control  is  naturally  present  after  forcible 
stretching  of  the  sphincter  muscle,  but  in  the  majority  of  cases  is 
partially  recovered  from  within  a  few  hours.  Removal  of  the  sensitive 
area  of  the  mucous  membrane  is  partially  responsible  for  loss  of  control ; 
hence  the  time  for  return  of  control  is  longer  after  the  Whitehead 
than  after  the  ligature  or  the  clamp-and-cautery  method  of  operating. 
But  recovery  after  the  Whitehead  method  is  usually  complete  in  a  fort- 
night, and  practically  always  in  three  weeks.  When  the  sphincter 
has  been  stretched  by  piles  for  months  or  years  before  operation, 
and  again  forcibly  at  operation,  re-establishment  of  muscular  power  is 
slower.  In  such  cases  the  sphincters  should  not  be  stretched  more 
than  is  absolutely  necessary. 

(e)  Stricture. — This  never  follows  the  clamp-and-cautery  method 
or  the  excision  of  individual  piles.  It  may  follow  the  ligature  or  the 
Whitehead  operation.  In  the  latter,  union  by  first  intention  practically 
never  occurs,  but,  the  stitches  giving  way  about  the  fourth  or  fifth  day, 
the  mucosa  retracts  for  a  variable  distance.  The  tendency  to  stricture 
is  proportionate  to  the  degree  of  retraction  of  the  mucosa.  In  the 
ligature  operation  healthy  mucosa  is  left  between  the  raw  surfaces, 
and  from  this  epithelium  will  be  regenerated.  Hence  the  tendency 
to  stricture  is  greater  after  the  Wliitehead  than  after  the  ligature 
operation.  After  either  operation  an  examination  should  be  made 
during  the  third  or  fourth  weeks,  and  any  contraction  will  then  be 
evident.  By  frequent  digital  stretching  when  the  fibrous  tissue  is  still- 
young,  a  stricture  of  sufficient  degree  to  cause  symptoms  may  usually 
be  entirely  prevented. 

Haemorrhoids  occasionally  recur,  or,  more  strictly  speaking,  fresh 
piles  form.  This  is,  however,  most  unusual  if  all  have  been  properly 
removed,  and  if  sufficient  care  be  taken  to  avoid  the  causes  which  are 
held  responsible  for  the  production  of  piles.  Naturally,  recurrence 
would  be  comparatively  more  frequent  after  the  clamp-and-cautery,  the 
excision  of  the  individual  pile  and  the  ligature  methods  of  operating 
than  after  the  Whitehead  operation.  But  it  is  stated  that  it  may  occur 
even  after  the  excision  of  the  "  pile-bearing  area." 

ANAL    FISSURE 

Definition. — An  elongated  narrow  ulcer  in  the  long  axis  of  the  anal' 
canal  within  the  sphere  of  influence  of  the  external  sphincter  muscle. 

Etiology  and  pathology. — Anal  fissure  occurs  most  fre- 
quently in  adult  life ;  it  is  rare  in  childhood  and  uncommon  in 
old  age.  Chronic  constipation  is  the  usual  predisposing  cause  ;  in  it 
the  sphincters  tend  to  become  hypertrophied  and  indurated,  the  anal 
canal  to  lose  elasticity  and  dilatability ;  the  hard  scybalous  mass 
actually  tears  the  skin  of  the  anal  orifice.     Healing  is  prevented  by 


ANAL    FISSURK  683 

the  stretching  due  to  defecation  and  by  the  activity  of  the  external 
sphincter  muscle.  A  fissure  is  usually,  though  not  always,  single  ; 
multiple  fissures  suggest  syphilis,  but  this  is  not  invariable.  A  fissure 
U  Bomewhat  pear-shaped  <>r  triangular  in  form,  broader  below  than 
above,  situated  between  the  normal  rugae  of  the  anal  orifice,  and 
<>t'  varying  length  and  depth,  often  the  upper  extremity  is  at  the 
lower  margin  of,  or  even  overlies,  the  internal  sphincter  muscle,  and 
the  lower  extremity  is  at  the  lower  margin  of  the  external  sphincter 
muscle.  At  first  it  is  quite  superficial,  but  later  its  base  may  be  formed 
by  the  muscles.  In  a  minority  of  cases  there  is  an  odematous  tag  of 
skin,  the  so-called  "  sentinel  pile/'  at  the  lower  end  of  the  fissure  and 
partly  obscuring  it.  This  may  occasionally  be  an  anal  valve,  torn 
down  during  defaecation,  but  more  often  is  one  of  the  normal  rugae, 
cedematous  through  infection  from  the  fissure. 

Fissure  may  rarely  result  from  partial  detachment  during  defaeca- 
tion  of  a  polypus  originating  low  in  the  rectum,  or  from  laceration 
during  the  passage  of  a  foreign  body.  It  may  also  follow  direct  infec- 
tion due  to  imperfect  cleansing  of  the  crevices  between  the  circum- 
anal ruga?. 

Symptoms. — Pain  of  a  characteristic  and  often  pathognomonic 
type  is  the  one  symptom.  It  occurs  during  defaecation,  and  lasts  for 
it  variable  time  after.  It  is  often  most  intense,  incapacitating  the 
patient  for  an  hour  or  more.  It  is  of  a  tearing  character,  and  radiates 
from  the  anus  to  the  perineum,  thighs,  and  back.  Its  severity  causes 
voluntary  abstention  from  defaecation,  with  consequences  disastrous 
to  the  fissure.  Sometimes  pain  is  not  so  severe,  but  passes  off  as  soon 
as  the  bowels  are  relieved.  The  degree  of  pain  appears  to  vary  with 
the  depth  of  the  fissure.  The  skin  of  the  anal  canal  is  richly  supplied 
with  sensory  nerves,  some  of  width  are  probably  exposed,  as  points 
of  exquisite  tenderness  may  be  found  by  passing  a  probe  over  the 
surface  of  the  fissure.  The  passage  of  faeces  over  the  raw,  sensitive 
surface  is  responsible  for  the  pain  during  defaecation,  and  the  spasm 
of  the  sphincter  muscle  for  its  persistence.  Haemorrhage  during 
defalcation  may  occur  ;  this  "is  usually  a  mere  drop,  but  occasionally 
is  more  extensive.  A  little  pus  is  secreted  from  the  fissure,  and  may 
cause  pruritus  ani  (p.  727).  The^spasmodic  contractions  of  the  sphincter 
muscle  during  defaecation  may  render  the  motions  somewhat  flattened 
or  tapering  in  shape. 

The  examination  must  be  conducted  with  all  gentleness.  On 
separating  the  circumanal  folds  a  fissure  will  be  readily  seen.  A 
digital  examination  is  usually  necessary  to  determine  the  presence 
or  absence  of  coexisting  disease. 

Treatment. — Palliative  measures  should  first  be  tried,  and 
will  often  greatly  relieve  a  recent  and  superficial  fissure.    Constipation 


684  RECTUM   AND   ANAL   CANAL 

must  be  effectually  treated,  and  the  motion  rendered  as  soft  as  possible 
by  the  injection  of  oil  into  the  bowel.  For  pain,  a  cocaine  ointment 
may  be  applied.  To  promote  healing,  a  stimulating  ointment  or 
powder,  e.g.  calomel  or  resin,  should  be  used.  If  these  measures  fail 
to  cure  in  three  or  four  weeks,  operation  should  be  earnestly  advised, 
for  this  painful  disease  causes  rapid  loss  of  flesh  and  great  depression. 
The  object  of  operative  treatment  is  to  secure  temporary  paralysis 
of  the  external  sphincter  muscle  by  its  division.  If  the  fissure  is  recent 
and  not  associated  with  other  conditions  requiring  operation,  local 
anaesthesia  may  be  employed,  but  whenever  possible  a  general  anaes- 
thetic should  be  given  to  ensure  more  thorough  treatment.  In  the 
former  case  the  base  of  the  fissure  is  infiltrated  with  eucaine  and 
adrenalin,  and  divided,  together  with  the  superficial  fibres  of  the 
external  sphincter  muscle.  The  "  sentinel  pile,"  if  present,  must  be 
removed,  otherwise  healing  will  not  follow.  If  general  anaesthesia  be 
adopted,  the  sphincters  are  dilated,  and  the  anal  margin  everted  with 
the  finger  inside,  so  as  to  bring  the  fissure  into  full  view.  An  incision 
is  then  made  through  the  fissure  and  the  whole  external  sphincter 
muscle,  and  prolonged  on  to  the  skin  for  \  in.  The  wound  must  be 
carefully  cleansed  after  defaecation,  and  made  to  heal  from  the  bottom. 
One  division  only  of  the  sphincter  is  necessary  to  secure  the  healing 
of  multiple  fissures.  Permanent  loss  of  control  never  follows  the 
operation. 

ABSCESS 

Suppuration  originating  in  disease  of  the  rectum  and  anal  canal 
occurs  in  definite  anatomical  situations.  The  following  varieties  of 
abscess  may  be  distinguished,  viz.  (1)  subcutaneous,  (2)  ischio-rectal, 
(3)  submucous,  (4)  pelvi-rectal,  and  (5)  labial.     (Fig.  500.) 

1.  Subcutaneous  Abscess 

This  is  situated  in  the  subcutaneous  tissue  at  or  near  the  anal 
margin.  It  originates  from  infection  of  either  a  sebaceous  follicle 
(the  follicular  abscess),  a  fissure,  or  an* external  pile.  The  follicular 
abscess  is  usually  single,  but  may  be  multiple  if  more  than  one  follicle 
be  infected.  It  is  situated  close  to,  but  not  at  the  anal  margin,  and 
has  no  tendency  to  burrow  towards  the  anal  canal ;  hence  a  fistula 
does  not  follow.  The  diagnosis  is  obvious,  and  the  treatment  by  a 
free  radial  incision  is  simple. 

An  abscess  originating  in  a  fissure,  or  in  a  thrombotic  or  inflamed 
external  pile,  is  situated  at  the  anal  margin,  and  tends  to  burrow 
towards  and  open  into  the  anal  canal  as  well  as  on  the  surface  of 
the  skin  at  a  variable  distance  from  the  anal  margin.  A  complete 
subcutaneous  fistula,  therefore,  frequently  results.      This  tendency  to 


ISGHIO-REGTAL    ABSCESS 


685 


open  into  the  anal  canal  should  be  anticipated  in  the  treatment)  which 
consists  in  freely  opening  the  abscess  into  the  anal  canal  by  a  radial 
incision.  The  incision  is  entirely  superficial  t<>  the  external  sphincter 
muscle. 

2.  Ischio-Rectal  Abscess 

The  ill-nourished  condition  of  the  fat  of  the  ischio-rectal  fossa 
predisposes  it  to  infection.  The  infection  may  arise  from  any  inflam- 
matory process  in  the  lower  part  of  the  bowel,  and  it  extends  to  the 
fossa  via  the  weak  point  in  the  bowel  wall,  i.e.  the  interval  between 
the  two  sphincter  muscles. 

Etiology. — An  inflamed 
internal  pile,  an  ulcer  in  one 
of  the  sinuses  of  Alorgagni, 
the  upper  extremity  of  an 
anal  fissure,  or  ulceration  fol- 
lowing operations,  may  all 
cause  an  ischio-rectal  abscess. 
But  frequently  none  of  these 
lesions  is  found,  and  in  all 
probability  bacteria  can  escape 
through  the  bowel  wall  with- 
out any  recognizable  lesion 
of  the  latter.  A  little  accu- 
mulation of  frecal  material  in 
one  of  the  sinuses  of  Mor- 
gagni  may  excite  some  in- 
flammation from  which  the 
fossa  may  be  infected.  Earely 
a  foreign  body  has  been  known 
to  perforate  the  bowel  wall, 
and  has  been  found  in  the 
pus  of  the  abscess.  The  bac- 
terium causing  the  suppura- 
tion is  either  the  Bacillus  coli,  or  the  common  pyogenetic  coccus 
alone  or  in  association  with  the  former. 

Suppuration  tends  to  spread  (1)  towards  the  skin  over  the  fossa  ; 
(2)  towards  the  bowel,  usually  between  the  two  sphincters,  or  occasionally 
through  the  fibres  of  the  external  or  internal  sphincter,  the  site  of 
pointing  or  rupture  being  determined  often  by  that  of  the  origin  of 
the  infection  ;  (3)  less  commonly  between  the  levator  ani  and  the  ano- 
coccygeal  ligament   posteriorly,   to   the   fossa   of  the   opposite   side ; 

(4)  very  rarely  through  the  levator  ani  to  the  pelvi-rectal  space  ; 

(5)  uncommonly  to  the  anterior  part  of  the  perineum  or  labium  majus. 
The  symptoms  are  those  attending  acute  suppuration.    A  fullness- 


Fig.  500. — Imaginary  section,  in  the 
coronal  plane,  of  the  rectum,  anal 
canal,  and  perirectal  tissues,  illustrat- 
ing the  various  positions  of  abscesses. 

I.T.,  Ischial  tuberosity  ;  e.s.,  external  sphincter  muscle  ; 
i.s.,  internal  sphincter  muscle  ;  l.a.,  levator  ani  muscle  ; 
0.1.,  obturator  internus  muscle  ;  F.,  fascia  covering  the 
obturator  internus  and  levatores  ani  muscles;  v.,  peri- 
toneum. Th^shaded  areas  represent  abscesses,  which 
are  thus  seen  in  the  submucous  tissue,  at  the  anal 
margin,  under  the  skin  a  little  distance  from  the  anal 
margin,  in  the  ischio-rectal  fossa,  and  between  the 
levator  ani  muscle  and  the  peritoneum,  the  potential' 
pelvi-rectal  space. 


-686  RECTUM  AND   ANAL   CANAL 

.in  the  fossa  may  be  appreciated  both  externally  and  internally.  If 
allowed  to  progress,  redness  and  oedema  of  the  skin,  and  eventually- 
fluctuation,  will  appear. 

Treatment. — An  acute  inflammatory  mass  in  the  ischio-rectal 
-fossa  should  be  incised  at  once,  even  before  the  presence  of  pus  is 
certain.  Early  operation  will  materially  shorten  convalescence  and 
perhaps  prevent  the  subsequent  formation  of  a  fistula. 

Under  anaesthesia  a  curved  incision  is  made,  parallel  to  the  anal 
margin  over  the  most  prominent  part  of  the  swelling,  and  extended 
anteriorly  and  posteriorly  beyond  the  limits  of  the  swelling.  A  second 
i  incision  is  made  at  right  angles  to  this  outwards,  well  beyond  the 
limits  of  the  induration.  The  finger  is  inserted  into  the  cavity,  and 
all  septa  broken  down.  Free  opening  is  necessary  to  prevent  the 
burrowing  of  pus,  which  so  constantly  results  from  any  smaller  incision 
and  leads  to  persistent  sinus  or  fistula.  The  abscess  usually  heals 
satisfactorily  under  such  treatment,  but  a  sinus  may  persist,  or  a 
fistula  form,  and  require  further  treatment.  At  the  time  of  evacuating 
the  abscess  a  communication  with  the  rectum  may  be  present,  usually 
through  or  close  to  the  space  between  the  two  sphincters.  Should 
this  be  so,  or  if  merely  a  thin  stratum  of  mucosa  separate  the 
abscess  from  the  bowel  cavity,  the  case  should  be  treated  as  fistula  or 
cutaneous  sinus  (p.  689). 

3.  Submucous  Abscess 

An  abscess  in  the  submucosa  of  the  lower  rectum  shows  a  marked 
tendency  to  track  towards  the  anal  margin  and  open  there,  but 
also  burrows  to  some  extent  laterally  in  the  bowel  wall.  Usually 
this  abscess  bursts  of  its  own  accord,  but  if  seen  before  this  occurs 
it  should  be  opened  at  its  lower  margin.  Healing  is  generally 
rapid,  but  occasionally  a  submucous  track  persists  and  should  be 
freely  laid  open  in  the  longitudinal  direction,  care  being  taken  to 
check  all  haemorrhage,  which  may  be  free  from  one  of  the  terminal 
.branches  of  the  superior  hemorrhoidal  artery. 

4.  Pelvi-Rectal  Abscess 

This  abscess  is  a  suppurative  cellulitis  of  the  connective  tissue 
between  the  levator  ani  muscle  and  the  peritoneum.      This  tissue  is 
.  continuous  with  that  between  the  layers  of  the  pelvic  mesocolon  and 
the  broad  ligament,   and  also  with  that  surrounding    the    prostate 
.  and  the  neck  of  the  bladder.     Disease  of  the  latter  organs,  rather 
than  of  the  rectum,  is  more  frequently  responsible  for  a  pelvi-rectal 
abscess.    But  occasionally  ulceration  of  the  rectum,  malignant  disease, 
.  or  perforation  by  a  foreign  body  may  cause  an  infection  of  the  con- 
nective tissue  surrounding  the  bowel  above  the  levator  ani. 


FISTULA    AND   SINUS  <387 

The  ultra-acute  pelvi-rectal  infection  frequently  terminates  in  acute 
peritonitis  or  gangrenous  cellulitis.     The  more  subacute  or  chronic 

cases  present  the  symptoms  of  pelvic  cellulitis;  unless  recta]  ilisease 
is  known  to  exist,  the  cause  may  be  entirely  overlooked.  Rectal 
examination  may  demonstrate  a  unilateral  fullness  above  the  level  of 
the  internal  sphincter  muscle.  Pus  may  escape  into  the  bowel  with 
relief  of  symptoms,  but  drainage  will  probably  be  imperfect  and 
the  abscess  reaccumulate.  Sometimes  the  pus  may  track  through 
the  levator  ani,  or  posteriorly  through  the  median  raphe,  to  the  ischio- 
rectal fossa,  and  eventually  reach  the  surface  through  one  or  more 
openings.  In  other  cases  the  pus  may  track  to  the  iliac  or  lumbar 
regions,  or  even  through  the  sacro-sciatic  foramen  to  the  buttock. 

Treatment  is  a  difficult  matter,  and  depends  to  some  extent 
upon  the  cause.  Any  etiological  rectal  disease  must  be  appropriately 
treated.  Incisions  into  the  abscess  cavity  must  be  free,  and  may  be 
necessary  in  the  perineum  or  the  iliac  region,  or  both.  When  a  pelvi- 
rectal abscess  has  burst  into  the  ischio-rectal  fossa,  it  is  to  be  opened 
as  already  explained,  and  the  aperture  through  the  levator  ani  enlarged 
with  forceps  and  freely  drained. 

5.  Labial  Abscess 
This  abscess  is  generally  confined  to  the  labium  majus.    It  arises 
from  disease  of  the  anterior  part  of  the  lower  rectum  or  anal  canal. 
It  is  incised  in  a  manner  similar  to  that  adopted  for  the  ischio-rectal 
abscess. 

FISTULA  AND  SINUS 
A  fistula  is  a  suppurating  track  opening  both  on  to  the  cutaneous 
surface  and  into  the  lumen  of  the  bowel.  A  sinus,  on  the  other  hand, 
has  only  one  opening,  winch  may  either  be  on  to  the  cutaneous  surface, 
the  cutaneous  sinus,  or  into  the  lumen  of  the  bowel,  the  rectal  sinus. 
Both  the  sinus  and  the  fistula,  when  of  rectal  origin,  are  practically 
always  preceded  by  one  or  other  variety  of  perirectal  abscess.  Rarely 
will  a  foreign  body,  such  as  a  fish-bone,  perforate  the  rectal  wall  with- 
out the  formation  of  any  definite  abscess,  causing  at  first  a  rectal 
sinus  and  later  a  fistula. 

Fistula 

A  fistula  may  be  superficial,  intermuscular,  or  supramuscular, 
according  to  its  position  in  the  bowel  wall  (Fig.  501). 

Superficial  fistula. — The  track  is  superficial  to  the  external 
sphincter,  or  may  pass  between  the  superficial  fibres  of  the  muscle. 
It  results  from  a  subcutaneous  abscess  opening  both  on  to  the  surface 
and  into  the  anal  canal  at  the  anal  margin.  The  internal  orifice  of 
the  fistula  may  be  seen  at  the  base  of  a  fissure,  or  as  a  small  ulcer  at 


688 


RECTUM  AND   ANAL   CANAL 


the  anal  margin.  The  external  orifice  is  near  the  anus,  and  the  track 
is  seldom  more  than  1J  in.  in  length.  Since  the  fistula  is  so  super- 
ficial, the  discharge  so  slight,  and  the  inner  opening  not  really  into 
the  lumen  of  the  bowel  but  at  the  anal  margin,  and  free  from  the 
entry  of  faeces,  there  is  no  tendency  to  the  purulent  accumula- 
tions and  burrowing  of  the  pus  which  so  frequently  occur  in  the 
deeper  fistula?.  The  external  opening  is,  therefore,  practically  always 
single.  The  fistula  may  be  situated  anywhere  around  the  anus,  but 
is  very  frequently  located  posteriorly.    The  track  may  pursue  a  straight 

or  slightly  curved 
course. 

The  symp- 
toms of  a  super- 
ficial fistula  are 
slight.  Pain  is 
acute  before  the 
abscess  is  emptied, 
but  as  there  is  no 
tendency  to  bur- 
i.T.  rowing,  it  is  prac- 
tically absent  when 
the  fistulous  track 
is  established.  The 
discharge  is  com- 
paratively little. 
The  internal  orifice 
is  Easily  detected, 
and  the  fistula 
readily  permits  the 
passage  of  a  probe.  The  walls  of  a  superficial  fistula  have  been 
known  to  become  completely  epithelialized  from  the  margins  of  the 
orifices. 

The  treatment  consists  in  laying  the  track  completely  open  and 
allowing  the  wound  to  granulate.  When  the  track  passes  between 
the  superficial  fibres  of  the  external  sphincter,  this  muscle  must  be 
completely  divided  at  right  angles  to  the  direction  of  its  fibres,  in 
order  to  secure  rest. 

The  intermuscular  fistula  results  from  an  ischio-rectal 
abscess.  Spontaneous  rupture  of  an  ischio-rectal  abscess  will  almost 
certainly  lead  to  imperfect  drainage,  and  the  pus  tends  to  burrow  in 
various  directions,  and  not  infrequently  towards  the  bowel.  But  even 
when  drainage  is  timely  and  efficient  a  fistula  may  form  ;  for  the 
abscess  originates  from  and  may  be  in  close  proximity  to  a  lesion, 
e.g.  an  ulcer,  in  the  bowel,  and,  in  fact,  may  communicate  with  the 


Fig.  501. — Section  similar  to  that  in  Fig.  500, 
illustrating  the  positions  of  sinuses  and  fistulae. 

On  the  left  side  are  the  superficial  and  intermuscular  fistulae,  and  the 
internal  sinus  opening  into  the  bowel  above  the  internal  sphincter 
muscle.  On  the  right  is  the  internal  sinus  extending  into  the  pelvi- 
rectal space  and  opening  into  the  bowel  between  the  sphincter  muscles 
and  above  the  levator  ani  muscle.     For  lettering,  see  Fig.  500. 


INTERMUSCULAR    FISTULA  689 

interior  of  the  bowel  from  the  beginning,  or  the  diseased  bowel  wall 
may  be  readily  perforated  al  a  later  date.     The  internal  opening  of 

the  fistula  is  between  the  internal  and  external  sphincter  muscles,  or 
in  the  immediate  vicinity,  the  track  passing  through  the  fibres  of  one 

or  other  muscle.  The  reasons  for  this  fact  are  thai  the  disease  which, 
originally  caused  the  abscess  is  situated  in  this  region  of  the  bowel ; 
the  sloping  interna]  boundary  of  the  abscess  (the  levator  ani  and  ita 

fascia)  passes  to  the  bowel  between  the  sphincter  muscles,  and  will 
direct  the  pus  to  this  space  ;  the  main  branches  of  the  inferior  haemor- 
rhoidal  vessels  enter  the  bowel  here,  and  may  influence  the  direction 
in  which  suppuration  extends.  The  internal  opening  is  generally 
single.  When  two  internal  openings  are  present  there  are  either  two 
distinct  fistulas,  or  the  second  opening  is  higher  and  at  the  upper 
extremity  of  a  submucous  track,  an  offshoot  of  the  original  abscess. 
The  opening  is  frequently  situated  posteriorly  just  to  one  side  of  the 
mid-line.  This  is  probably  explained  either  by  the  better  develop- 
ment of  the  sinuses  of  Morgagni  posteriorly,  the  original  infection 
being,  therefore,  more  likely  to  arise  from  this  part  of  the  bowel,  or 
by  the  greater  interval  between  the  sphincters  posteriorly  permitting 
pus  to  track  there  more  readily. 

The  external  opening  of  the  fistula  is  at  first  single.  Imperfect 
drainage  and  burrowing  of  pus  frequently  lead  to  secondary  abscesses, 
which  open  spontaneously,  and  hence  multiple  external  openings  are 
by  no  means  uncommon.  They  may  be  situated  in  the  skin  over 
anv  part  of  the  ischio-rectal  fossa,  or  at  some  distance  from  this,  in 
the  buttocks  or  the  perineum.  An  ischio-rectal  abscess  may  track 
from  one  fossa  to  the  other.  The  external  openings  of  a  fistula  may 
therefore  be  on  opposite  sides  of  the  anus.  The  name  "  horseshoe- 
shaped  "  fistula  has  been  given  to  this  variety.  When  the  internal 
orifice  has  its  common  posterior  position  the  fistulous  track  is  curved 
or  tortuous.  When,  however,  the  internal  orifice  is  situated  laterally 
the  external  orifice  is  generally  immediately  opposite,  and  the  fistula 
is  short  and  direct. 

The  symptoms  of  an  intermuscular  fistula  are  various.  If  untreated, 
secondary  abscesses  form  sooner  or  later,  and  are  attended  by  the 
symptoms  of  pent-up  pus.  Flatus,  and  rarely  faeces,  may  escape  from 
a  fistula.  On  examination,  the  external  orifices  are  readily  detected. 
The  internal  orifice  may  generally  be  felt  or  seen,  but  sometimes  it 
cannot,  and  then  without  the  aid  of  an  anaesthetic  the  diagnosis 
between  a  fistula  and  a  cutaneous  sinus  is  impossible.  The  track  of 
an  old-standing  fistula  may  be  felt  as  an  indurated  cord  in  the  tissues. 
The  passage  of  a  probe  is  often  impeded  by  the  tortuosity  of  the 
fistula,  and  is  unnecessary  before  operation. 

Treatment. — Operation  is  the  only  satisfactory  treatment  of  an 
2  s 


RECTUM    AND   ANAL    CANAL 

intermuscular  fistula,  and  in  the  a  I  any  special  contia-indicatiorj 

should  be  earnestly  advised.  It  consists  essentially  in  .slitting  up  the 
original  fistulous  track  and  all  secondary  sinuses  leading  from  it.  In 
order  to  do  this  the  internal  orifice  must  be  found.  If  the  probe  can 
be  passed  along  the  whole  length  of  the  fistulous  track,  all  structures 
superficial  to  it  are  divided,  including  the  external  sphincter  muscle. 
If  a  probe  cannot  be  passed  right  through,  it  should  be  introduced 
either  from  the  cutaneous  surface  or  the  internal  orifice  as  far  as 
possible,  the  sinus  slit  up,  and  the  other  aperture  carefully  sought 
and  enlarged.  It  is  imperative  that  no  artificial  opening  be  made 
into  the  bowel  and  then  enlargi  d  on  the  supposition  that  it  is 
the  fistula.  The  original  communication  with  the  bowel  must  in  all 
be  found,  and  this  opened  up,  otherwise  the  fistula  obviously 
will  not  heal.  "When  the  main  track  has  been  thus  treated,  all  secondary 
offsho<  •   be  freely  enlarged,  and  ample  drainage   provided    for 

them.  A  submucous  track,  not  infrequently  present,  should  also  be 
-lit  up.  The  external  sphincter  muscle  should  only  be  divided 
in  one  place,  and  transversely  to  the  direction  of  its  fibres.  If  this 
rule  be  followed,  incontinence  of  faces  will  not  result.  All  overhanging 
skin  and  mucous  membrane  must  be  removed.  The  wound 
must  be  carefully  dressed  to  ensure  healing  from  the  bottom. 

Should  operation  be  refused  or  inadvisable,  scrupulous  cleanliness 

be  enforced,  and  stimulating  lotions  e.g.  silver  nitrate,  copper 

sulphate.  Friar-  balsam,  tincture  of  iodine,  injected  along  the  track. 

A  supramuscular  fistula  tracks  through  the  bowel  wall 
above  the  internal  sphincter  muscle,  and  arises  from  rectal  ulceration, 
pelvi-rectal  abscesses,  or  very  rarely  from  the  burrowing  of  an  ischio- 
rectal abscess  through  the  levator  ani  muscle  with  secondary  rupture 
into  the  bowel.  The  orifices  vary  greatly  in  position;  not  infrequently 
they  are  multiple  internally.  Suppuration  may  extend  right  around 
the  bowel  in  the  pelvi-rectal  space,  both  anteriorly  and  posteriorly, 
reaching  the  surface  through  many  points.  The  course  and  direction 
of  these  fistula?  and  their  symptomatology  are  so  indefinite  that  no 
concise  account  of  them  can  be  given. 

The  treatment  is  largely  that  of  the  original  disease  ;  thus, 
malignant  disease  frequently  demands  a  palliative  colostomy.  Ulcera- 
tion and  stricture  are  discussed  later  (pp.  698,  704).  For  the  fistula 
itself  the  only  certain  plan  is  to  lay  the  track  freely  open  and  pack 
lightly  with  gauze.  In  some  cases  it  is  possible  to  excise  the  whole 
lining  membrane  of  the  split  fistula,  to  close  the  opening  into  the 
bowel,  and  then  to  close  the  track,  at  any  rate  in  its  deeper  part,  by 
a  series  of  buried  catgut  sutures,  special  care  being  taken  to  reconstitute 
the  divided  internal  sphincter. 

But  as  splitting  of  the  whole  track  involves  division  of  both  sphincters 


SIM    S  691 

tails    grave    risk  of  fasca]    incontinence;    therefore    less  d 
measures  may  be  tried  first.    The  externa]  pari  of  the  fistnla  may  be 
laid  opm.  and  tin-  rest  Byringed  periodically  with  Btimnlating  lotions, 

such  as  silver  nitr.it :  tincture  <>f  iodine.    This  will  sometimes  be 

successful.  Division  of  both  sphincters  Bhould  be  reserved  for  fistulas 
causing  severe  trouble,  and  Bhould  only  be  done  with  the  patient's 
full  knowledge  of  the  possible  consequent 

For  the  treatment  of  tuberculous  fistulas,  see  p.  695. 

Sin 

The  cutaneous  sinus  results  from  an  ischio-rectal  abscess, 
or  occasionally  from  a  pelvi-rectal  abscess,  reaching  the  surface  1 1 

the  levator  ani  and  ischio-rectal  fossa.  The  imperfect  drainage  <>f  tin- 
sinus,  the  constant  movements  to  which  it  is  subjected,  and  its  fre- 
quent extension  to  the  sphere  of  influence  of  the  sphincter  muscles, 
factors  which  tend  to  prevent  healing. 

The  differentiation  between  a  cutaneous  sinus  and  a  fistula  is  often 
difficult,  and  requires  patience  and  manipulative  skill.  Inability  to 
1  probe  through  the  sinus  into  the  bowel  does  not  necessarily 
mean  that  no  communication  exists.  The  passage  of  faeces  or  flatus 
through  the  track,  or  the  discovery  of  an  internal  opening,  establishes 
the  diagnosis  of  fistula. 

The  treatment  of  a  cutaneous  sinus  is  very  similar  to  that  of  a 
fistula.  It  must  be  freely  opened  up,  and  will  then  often  be  found  to 
track  towards  the  bowel,  being  only  separated  from  it  by  a  thin  layer 
of  tissue.  The  track  generally  passes  towards  the  interval  between 
the  sphincters.  When  it  is  certain  that  there  is  no  aperture  of  com- 
munication with  the  bowel,  one  should  be  made  by  passing  the  probe 
through  the  thinnest  portion  between  the  sphincters,  thus  converting 
the  sinus  into  a  fistula  ;  as  such  it  is  then  treated.  Should,  however, 
the  track  pass  in  connexion  with  the  bowel  above  the  level  of  the 
internal  sphincter  muscle,  this  treatment  should  not  be  advised,  for 
it  would  mean  division  of  the  internal  sphincter,  and  in  all  probability 
incontinence  of  fasces  would  result.  In  such  cases  the  sinuses  may  be 
enlarged,  free  drainage  provided,  and  some  stimulating  lotion  injected 
from  time  to  time.    The  whole  sinus  wall  may  sometimes  be  excised. 

In  the  rectal  sinus  the  aperture  of  communication  with  the 
bowel  may  be  situated  between  the  two  sphincter  muscles,  or  in  close 
proximity,  or  less  frequently  above  the  level  of  the  internal  sphincter 
muscle.  The  rectal  sinus  results  from  the  rupture  of  an  ischio-rectal 
or  a  pelvi-rectal  abscess  into  the  bowel.  Drainage  is  nearly  always 
inefficient ;  the  orifice  into  the  bowel  frequently  becomes  temporarily 
occluded,  and  pus  reaccumulates.  The  symptoms  are  those  of  re- 
curring attacks  of  perirectal  suppuration  with  periodical  discharges  of 


692  KKCTUM    AND   ANAL    CANAL 

pus  from  the  bowel.  On  examination  an  induration  may  be  felt  in 
the  ischio-rectal  fossa,  more  evident  at  times  than  at  others.  With  a 
speculum  the  internal  orifice  may  be  seen,  and  pus  observed  to  issue 
from  it. 

Cure  cannot  be  expected  without  operation,  since  the  drainage 
from  the  abscess  into  the  bowel  is  always  inefficient. 

Treatment. — (a)  When  the  internal  orifice  is  between  the  sphincter 
muscles  a  probe  should,  if  possible,  be  passed  through  the  orifice, 
directed  towards  the  surface,  and  its  end  exposed  by  incising  the  tissues 
superficial  to  it.  Or,  if  the  swelling  is  palpable,  it  may  be  incised  from 
the  surface.  In  either  case  the  sinus  is  converted  into  a  fistula  and 
treated  as  such,  (b)  When  the  orifice  is  above  the  internal  sphincter  muscle 
the  operation  performed  as  above  would  necessarily  divide  the  muscle, 
and  incontinence  of  faeces  would  probably  result.  A  rectal  sinus  above 
the  internal  sphincter  nearly  always  arises  from  some  ulceration  of 
the  bowel,  and  this  must  be  treated.  The  abscess  should  be  incised 
from  the  surface,  efficient  drainage  provided,  and  the  track  through 
the  bowel  wall  treated  as  for  a  fistula  in  this  region  (p.  690). 

Complicated  Fistula 

Under  this  heading  are  included  some  of  the  rarer  forms  of  rectal 
fistula.  Two  varieties  may  be  considered  :  (1)  the  fistula  communicat- 
ing with  some  adjacent  viscus — the  bladder,  the  urethra,  or  the  vagina  ; 
and  (2)  the  fistula  dependent  originally  upon  some  chronic  bone  disease. 

1.  (a)  Recto-vesical  fistula. — This  may  be  caused  by  rectal 
ulceration  spreading  to  the  bladder,  by  a  pelvi-rectal  abscess  opening 
both  into  the  bowel  and  the  bladder,  or  more  rarely  by  injuries,  such 
as  bullet  wounds  or  buffer  crushes. 

The  typical  symptoms  of  a  recto-vesical  fistula  are  those  caused 
by  the  escape  of  the  contents  of  one  viscus  into  the  other.  Urine  may 
pass  into  the  rectum  or  faeces  into  the  bladder,  and  theoretically  it 
would  seem  that  both  may  occur.  Practically,  however,  a  valve-like 
action  develops,  and  the  current  is  only  in  one  direction.  Severe  cystitis 
and  the  presence  of  faeces  in  the  bladder  cause  extreme  suffering  and 
painful  micturition.  Excoriation  of  the  skin  of  the  anal  region  may 
occur  from  the  constant  passage  over  it  of  urine. 

The  treatment  varies  with  the  cause  of  the  fistula.  If  this  is 
due  to  malignant  disease,  and  faeces  are  entering  the  bladder,  a  palliative 
colostomy  is  indicated,  though  the  less  distressing  symptoms  of  urine 
escaping  into  the  bowel  will  not,  of  course,  be  relieved.  Cystectomy 
may  be  necessary  in  some  cases  where  micturition  is  extremely  painful. 
When  the  fistula  is  narrow  and  of  inflammatory  origin,  success  has 
attended  cauterization  through  a  long  rectal  speculum,  with  or  without 
a  preliminary  posterior  proctotomy.     When  this   fails,   or  when  the 


COMPLICATED    I- IS  I  II  ..]■:  693 

orifice  is  large,  cure  can  only  !>'•  obtained  by  perinea]  dissection,  separat- 
ing the  rectum  from  the  prostate  and  bladder,  paring  the  edges  and 
Buturing  them.  The  operation  is  severe  anil  difficult,  and  often 
attended  with  failure. 

(b)  Recto-urethral  fistula  usually  results  from  urethral  dis- 
ease (e.g.  a  stricture),  and  very  rarely  from  penetrating  wounds.  The 
symptoms  are  those  of  the  original  urethra]  disease  and  the  past 

of  mine  into  the  how  el  during  micturition.  The  treatment  is,  in  the 
first  place,  that  of  the  original  disease  A  stricture  should  be  dilated 
and  the  urine  drawn  off  by  catheter.  This  simple  measure  may  be 
successful.  If  it  fail,  the  fistula  should  be  exposed  by  a  dissection 
from  the  rjerineum,  and  the  apertures  closed  with  sutures. 

(c)  Recto-vaginal  fistula  may  be  due  to  any  form  of  peri- 
rectal  suppuration  which  opens  both  into  the  bowel  and  the  vagina, 
to  injuries  during  parturition,  to  tuberculous  or  syphilitic  infection 
of  either  the  bowel  or  the  vagina  or  both,  and  also  to  cancer  originating 
in  either  viscus.  The  symptoms  peculiar  to  a  recto-vaginal  fistula 
are  the  passage  of  flatus  and  foeces  from  the  bowel  to  the  vagina.  The 
treatment  of  the  fistula  obviously  depends  upon  the  cause.  If  due 
to  malignant  ulceration  the  disease  in  all  probability  will  be  too  exten- 
sive for  removal,  and  a  palliative  colostomy  is  indicated.  Syphilitic 
and  tuberculous  disease  must  be  appropriately  treated  before  any 
attempt  is  made  to  close  the  fistula.  When  the  aperture  is  of  small 
size,  cauterization  may  effect  a  cure.  In  other  cases  the  edges  of  the 
fistula  may  be  pared  and  sutured  either  from  the  vagina  or  from  the 
rectum  as  seems  most  accessible.  In  yet  others  the  fistula  may  be 
exposed  by  a  perineal  dissection,  the  edges  of  the  openings  pared,  and 
approximated  by  sutures. 

2.  Fistula  dependent  upon  bone  disease. — Abscesses 
arising  from  bone  disease  occasionally  open  into  the  rectum.  A  psoas 
abscess  which  enters  the  pelvis  by  perforating  the  sheath  of  the  muscle, 
an  abscess  originating  from  the  sacrum  or  ischium,  or  perhaps  more 
frequently  an  abscess  due  to  coccygeal  caries,  are  examples  of  those 
which  may  communicate  with  the  rectum.  The  diagnosis  is  usually 
easy  from  the  history  of  the  case  and  the  physical  examination. 
Radiography  may,  when  necessary,  aid  the  diagnosis  of  bone  disease. 
The  treatment  of  these  fistulas  is  that  of  the  original  bone  disease. 

INFLAMMATION— PROCTITIS 

Much  remains  to  be  learnt  about  the  bacteriology  of  proctitis,  and 
the  classification  adopted  is  clinical  rather  than  pathological.  For 
clinical  purposes  proctitis  may  be  considered  under  the  heads  of 
Simple  Catarrhal  Proctitis,  Gangrenous  Proctitis,  Proctitis  due  to 
Specific  Organisms,  and  Ulcerations. 


694  RECTUM   AND   ANAL    CANAL 

Catarrhal   Proctitis 

Acute  catarrhal  proctitis  may  be  caused  by  injury,  by  the  irritation 
of  scybalous  masses,  violent  purgatives,  or  thread-worms,  or  it  may 
be  a  part  of  a  generalized  colitis. 

The  symptoms  are  rectal  tenesmus  and  the  passage  of  muco-pus 
tinged  with  blood.  The  mucosa  is  very  swollen  and  vascular.  The 
frequent  straining  at  defsecation  renders  the  swollen  mucosa  liable  to 
prolapse.     Reflex  urinary  symptoms  are  frequently  present. 

The  course  and  terminations  are  various.  Some  cases  resolve  in 
a  few  days,  others  become  chronic,  and  occasionally  ulceration  follows. 

Chronic  catarrhal  proctitis  is  usually  a  sequel  of  the  acute  form, 
and  the  symptoms  are  similar  but  modified  in  degree.  The  rectal 
mucosa  is  swollen,  pale  and  cedematous,  and  covered  with  tenacious 
muco-pus.  Cell  proliferation  in  the  submucous  tissue  leads  to  con- 
siderable thickening  of  the  rectal  wall.  Superficial  ulceration  may  be 
present. 

Treatment. — In  the  acute  form,  rest  in  bed,  a  diet  which  leaves 
the  least  residue,  and  regulation  of  the  bowels  with  mild  aperients 
are  essential.  Occasional  hot  hip-baths  give  relief.  When  the  disease 
has  become  chronic  similar  treatment  is  necessary,  and  the  rectum 
should  be  irrigated  with  some  astringent  lotion  through  a  double- 
channelled  catheter,  or,  better,  a  direct  application  of  silver  nitrate 
or  iodine  should  be  made  to  the  diseased  mucosa. 

Diffuse  Septic  and  Gangrenous  Proctitis 

This  is,  nowadays,  a  very  rare  condition.  Formerly  it  was  seen 
after  operations  upon  the  rectum,  and  was  apparently  infectious.  The 
infective  process  involved  the  rectum  and  the  perirectal  tissues,  and 
was  not  infrequently  fatal.  If  recovery  took  place,  it  only  did  so 
after  prolonged  suppuration  and  sloughing,  leaving  the  tissues  per- 
manently damaged,  e.g.  by  strictures  of  the  bowel  and  destruction 
of  the  sphincter  muscles. 

Proctitis  due  to  Specific  Organisms 
Gonorrhoea!  proctitis  is  rare.  It  occurs  more  frequently  in 
the  female  by  direct  infection  from  the  vagina  ;  in  the  male  it  results 
from  unnatural  coitus.  The  symptoms  are  those  of  catarrhal  proctitis. 
The  diagnosis  is  founded  upon  the  bacteriological  examination.  The 
treatment  is  similar  in  the  acute  stage  to  that  of  catarrhal  proctitis. 
When  the  disease  has  become  chronic,  douches  of  protargol,  chinosol, 
or  some  mercurial  lotion  should  be  employed,  or  a  direct  application 
of  one  of  these  substances  should  be  made  to  the  diseased  mucosa. 

Diphtheria  very  rarely  attacks  the  rectum  and  anal  canal. 
Occasionally  it  has  been  seen  in  association  with  the  disease  in  the 


TUBERCULOUS   PROCTITIS  695 

throat,  and  it  is  said  that  the  lesions  in  the  perineum  have  preceded 
those  in  the  more  common  situations.  It  is  also  stated  that  diphtheria 
has  followed  an  operation  in  this  region.  The  signs,  diagnosis,  and 
treatment  are  similar  to  those  of  the  disease  in  the  usual  situations. 

Tuberculosis  is  not  uncommon,  and  is  usually  secondary  to 
pulmonary  disease.  It  is  stated,  however,  that  the  lesion  may  be 
primary,  the  bacilli  entering  with  the  food.  Imperfect  gastiic  digestion 
may  permit  the  passage  of  undestroyed  bacilli,  which  may  lodge  in 
the  anal  sinuses  and  there  cause  single  or  multiple  tuberculous  ulcers. 
The  ulcer  is  small  and  shows  no  tendency  to  spread  widely  over  the 
surface  of  the  bowel,  though  it  is  very  apt  to  perforate  to  the  perirectal 
tissues.  Usually  the  first  indication  of  the  disease  is  a  slowly  forming 
ischio-iectal  abscess,  which  differs  from  the  acute  abscess  already 
described  in  its  slower  development  and  less  severe  symptoms.  The 
abscess  tends  to  burrow  in  the  fossa,  eventually  making  its  way  to  the 
surface  and  discharging  through  one  or  more  openings  which  show 
the  undermined  edges  and  bluish  discoloration  of  the  surrounding 
skin,  and  the  prominent  pale  granulations  characteristic  of  tuberculous 
sinuses. 

Clinically  the  tuberculous  fistula  may  generally  be  differentiated 
by  the  following  points  :  The  buttocks  are  thin  and  the  ischio-rectal 
fossa  feebly  developed  ;  the  perineal  hair  is  abundant,  long  and  silky ; 
the  abscess  preceding  the  fistula  forms  insidiously,  the  external  orifice 
is  more  or  less  characteristic  of  a  tuberculous  sinus,  the  discharge  is 
thin  and  watery,  and  the  internal  opening  is  often  easily  felt  and  seen, 
being  sometimes  so  large  as  to  admit  the  finger-tip.  It  can  only  be 
certainly  diagnosed  by  finding  the  tubercle  bacillus  in  the  discharge, 
or  by  the  microscopy  of  the  granulation  tissue  lining  the  sinus. 

For  treatment  the  subjects  of  tuberculous  fistula  may  be  divided 
into  three  classes  : 

(a)  Fistula  associated  with  advanced  pulmonary  tuberculosis. — As 
little  should  be  done  as  is  consistent  with  relief  of  symptoms.  If  the 
abscess  has  not  burst  externally,  but  a  rectal  sinus  is  present,  consider- 
able pain  may  be  caused  by  the  passage  of  fseces  into  and  the  accumu- 
lation of  pus  in  the  cavity.  Under  local  anaesthesia  external  drainage 
should  be  provided.  No  active  interference  should  be  considered  if 
free  drainage  is  already  established. 

(b)  Fistula  associated  with  chronic  tuberculosis. — In  the  majority  of 
these  cases  an  attempt  may  be  made  to  cure  the  fistula,  and  with 
considerable  prospect  of  success. 

(c)  Fistula  not  associated  with  pulmonary  tuberculosis. — In  these 
cases  there  is  a  liability  to  the  later  development  of  pulmonary  tuber- 
culosis. Every  endeavour  should  be  made  to  cure  the  fistula.  All  the 
tracks  should   be   slit  up  and  their  walls  scraped,  or  in  some  cases 


RECTUM   AND   ANAL   CANAL 


Wmk 

:•••-■•••  ■.'■"-.>  r.  -u  \  *  -■■  ■'$'■ 


the  whole  track  may  be  dissected  out.  The  communication  with  the 
bowel  should  be  laid  open  as  in  the  simple  fistula.  The  wound  may 
be  partially  closed  by  sutures,  and  primary  union  in  part  may  be 
anticipated. 

Of  greater  rarity  than  the  above  is  the  variety  in  which  the  tubercles 
■ire  deposited  irregularly  in  the  mucous  or  submucous  tissues  of  the 
bou-el  wall  (Fig.  502).  These  degenerate,  and  finally  ulceration  ensues. 
The  tuberculous  ulcer  may  be  seen  on  any  part  of  the  rectal  wall.  At 
first  it  is  superficial  with  thin  undermined  edges,  and  on  its  floor  may 

perhaps  be  seen 
caseating  areas. 
The  surround- 
ing mucosa  be- 
comes much 
swollen,  and 
probably  shows 
yellowish  areas 
of  caseating  tu- 
bercle. Adja- 
cent ulcers  will 
coalesce  until 
a  considerable 
part  of  the  rec- 
tal wall  is  in- 
volved ;  indeed, 
in  some  ad- 
vanced cases 
almost  the  en- 
t  ire  rectum 
may  be  in- 
vaded. The  ul- 
ceration may 
spread  to  the 
anal  canal  and  destroy  the  sphincters.  The  depth  of  a  tuberculous 
ulcer  is  very  variable.  If  it  is  allowed  to  progress  the  muscular  wall 
may  become  eroded,  the  peritoneum  involved,  or  suppuration  may 
occur  in  the  pelvi-rectal  space  or  in  the  ischio-rectal  fossa. 

The  symptoms  are  those  of  ulceration  of  the  rectum,  described  at 
p.  698.  The  condition  has  to  be  diagnosed  from  chronic  septic  ulcera- 
tion, syphilis,  and  malignant  disease.  In  a  great  majority  of  cases  pul- 
monary tuberculosis  is  present.  Diagnosis  is  only  established  by  the 
examination  of  the  granulation  tissue  or  the  discovery  of  the  tubercle 
bacillus  in  the  scrapings  of  the  ulcer.  The  latter  is  generally  an  easy 
matter  in  this  form  of  ulceration.     The  course  of  the  disease  varies 


Fig.  502.- — Section,  taken  near  the  edge  of  the  ulcer, 
from  a  case  of  extensive  tuberculous  ulceration  of 
the  rectum,  showing  the  submucous  tuberculous 
infiltration. 


TUBERCULOUS   PROCTITIS  697 

Since  pulmonary  tuberculosis  is  usually  present,  the  rectal  ulceration 
tends  to  progress  even  when  treated.  In  a  few  cases,  under  treatment 
the  disease  runs  a  more  chronic  course;  librosis  occurs,  and  in  part 
the  ulceration  may  heal. 

Although  tuberculous  disease  is  often  given  as  a  rare  cause  of 
rectal  stricture,  the  evidence  is  by  no  means  conclusive  that  the  healing 
of  a  deep  tuberculous  ulcer  ever  progresses  sufficiently  to  narrow  the 
lumen  materially. 

The  treatment  of  tuberculous  ulceration  of  the  rectum  depends 
upon  the  severity  of  the  pulmonary  affection  and  the  extent  of  the 
ulceration.  In  advanced  pulmonary  disease  very  little  can  be  done, 
except  by  astringent  injections,  to  relieve  the  distress  caused  by  the 
constant  discharge.  If  the  pulmonary  affection  permits  "of  any  operative 
procedure,  and  the  ulcer  is  of  only  moderate  size,  it  may  be  excised. 
If  larger,  the  ulcer  should  be  thoroughly  scraped  and  the  raw  surface 
cauterized,  or  smeared  with  pure  carbolic  acid,  and  dusted  with  iodo- 
form powder.  This  may  have  to  be  repeated  should  the  ulceration 
spread,  or  a  fresh  ulcer  arise*  When  the  disease  is  extensive  the  only 
method  of  cure  is  by  complete  excision  of  the  rectum.  This,  in  the 
great  majority  of  cases,  is  not  permissible  on  account  of  the  pulmonary 
affection.    Perirectal  suppuration  must  be  treated  as  already  described. 

A  third  variety  of  tuberculous  disease  occurs  in  which  the  inflam- 
mation is  limited  to  the  skin  of  the  anal  canal  and  the  immediate 
'perianal  region.  Excluding  the  cutaneous  affection  which  occurs  around 
the  orifices  of  tuberculous  fistula?,  tuberculosis  of  the  anal  skin  is  very 
rare.  When  occurring  the  disease  is  very  chronic,  involves  the  anal 
canal,  but  does  not  tend  to  spread  to  the  mucosa.  The  appearance 
resembles  that  of  hypertrophic  lupus.  The  bacilli  are  difficult  of  de- 
tection in  this  lesion,  but  the  microscopic  structure  of  the  granuloma 
is  characteristic.  The  affected  area  of  skin  should  be  completely 
removed. 

Syphilis. — Various  syphilitic  lesions  occur  in  the  rectum  and 
anal  canal.  The  primary  chancre  has  been  observed  rarely  at  the  anal 
margin,  and  even  on  the  rectal  mucosa.  In  the  secondary  period 
moist  papules  and  condylomata  occur  at  the  anal  margin,  and  may 
extend  into  the  anal  canal ;  multiple  fissures  similar  to  those  in  the 
lips  and  tongue  occur  at  the  anal  margin,  and  mucous  tubercles 
have  been  seen  on  the  rectal  mucosa.  In  the  tertiary  period,  multiple 
localized  gummata  and  diffuse  gummatous  infiltration  may  occur  in  the 
submucosa  and  spread  deeply  into  the  muscular  walls,  but  they  are 
decidedly  rare.  Ulceration  may  follow,  and  the  coalescence  of  several 
large  ulcers  may  cause  wide  and  irregular  tissue  destruction.  A  gum- 
matous ulcer  has  been  known  to  invade  neighbouring  parts,  e.g.  the 
bladder    and    vagina,  and    fistula?  may  occur    between  these  viscera. 


698  RECTUM   AND   ANAL   CANAL 

Although  it  has  been  customary  to  assign  to  tertiary  syphilis  a  promi- 
nent place  in  the  etiology  of  chronic  rectal  ulceration,  probably  it  is 
but  seldom  an  effective  cause. 

There  is  a  decidedly  rare  form  of  diffuse  gummatous  infiltration, 
called  by  Founder  the  "  ano-rectal  syphiloma."  Commencing  in  the 
submucous  tissue,  it  involves  a  considerable  part  of  the  rectal  wall, 
with  or  without  implication  of  the  anal  canal.  Ulceration  may  or 
may  not  occur.  The  bowel  wall  is  converted  into,  a  rigid  and  much 
thickened  tube,  which  later  becomes  diminished  in  size  by  fibrous 
contraction.  It  appears  to  be  analogous  to  the  diffuse  syphilitic 
deposit  which  occurs  in  other  viscera,  e.g.  the  liver  and  testicles.  Anti- 
syphilitic  treatment  in  the  early  stage  gives  good  results,  but  later, 
when  fibrosis  has  occurred,  is  of  little  value. 

Chancroids  (see  Vol.  I.,  p.  834)  occur  on  the  skin  in  the 
vicinity  of  the  anus.  They  are  much  more  common  in  the  female, 
and  arise  by  direct  infection  from  the  vulval  discharge.  The  sores  are 
multiple,  and  in  appearance,  prognosis  and  treatment  are  similar  to 
those  occurring  on  the  genitals.  Occasionally,  the  ulcerating  chancroid 
may,  without  doubt,  extend  into  the  rectum.  According  to  some,  this 
is  one  cause  of  chronic  ulceration  of  the  rectum,  but  it  must  be  a 
decidedly  rare  one. 

Dysentery. — Many  different  forms  of  rectal  ulceration  have 
been  ascribed  to  dysentery,  but  the  term  should  be  reserved  for  cases 
caused  by  the  organisms  of  tropical  dysentery.  The  rectum  may  be 
involved  in  true  dysentery,  but  probably  only  in  association  with 
disease  in  the  colon.  The  ulcerations  are  then  superficial,  and  in  their 
healing  give  rise  to  but  little  contraction.  It  is  stated,  however,  that 
occasionally  a  stricture  productive  of  symptoms  may  follow. 

Actinomycosis  may  very  rarely  occur  in  the  perianal  skin  and 
in  the  anal  canal. 

ULCERATION 
Septic  ulceration  of  rectal  sinuses — When  Avell  de- 
veloped, the  sinuses  peculiarly  lend  themselves  to  the  lodgment  of  faecal 
material,  which  may  cause  abrasions  and  open  the  path  for  septic 
infection.  Though  occasionally  two  or  more  may  be  present,  the  ulcer 
is  usually  single,  situated  dorsally,  and  may  be  as  large  as  a  three- 
penny piece.  Symptoms  may  be  absent ;  but  sometimes  pain  radiating 
around  the  perineum  and  down  the  thighs  is  present  without  any 
relation  to  defaecation  ;  it  differs  from  that  of  a  fissure,  since  the  ulcer 
is  above  the  level  of  the  external  sphincter  muscle.  Sometimes  there 
are  traces  of  blood  and  pus  in  the  motions,  and  pruritus  ani  may 
be  present.  Discovery  of  an  ulcer  in  a  sinus,  concealed  by  a  swollen 
valve,  may  be  difficult  without  anaesthesia  ;    hence  a  faulty  diagnosis  of 


RECTAL   ULCERATION  699 

rectal  neuralgia  baa  been  made  in  some  cases.    An  ulcer  in  the  sinus 

may  cause  infection  ill  the  ischiorectal  fossa,  and  possibly  may  rai 
he   the   starting-point    of  chronic   diffuse    ulceration. 

Ulceration  caused  by  injuries. — Accidental  wounds  <>[  the 
rectum  are  rare,  hut  may  initiate  chronic  diffuse  ulceration.  Ulcera- 
tion has  followed  injury  with  the  stem  of  an  enema  t  uhe,  and  also  wound- 
made  for  the  removal  of  haemorrhoids,  etc.  ;  this  postoperative  danger  is 
enhanced  it  the  patient  be  feeble  and  resume  the  upright  posture 
before  the  wound  has  healed.  Some  authorities  consider  thai  erosions 
of  the  mucosa  by  hard  scybalous  masses  may  be  a  possible  starting- 
point  of  a  progressive  ulceration.  Portions  of  the  rectal  wall  may  be 
so  severely  damaged  by  the  passage  of  the  foetal  head  during  labour 
that  an  infective  gangrene  may  ensue.  In  such  cases  large  portions 
of  the  mucosa  or  even  the  deeper  parts  of  the  bowel  wall  may  slough. 
This  latter  cause  is  held  b)r  some  to  be  a  cause  of  chronic  septic  ulcera- 
tion, and  in  this  way  it  is  sought  to  explain  the  greater  frequency  of 
ulceration  in  the  female  sex. 

Follicular  ulceration  is  rare.  Numerous  ulcers,  more  or 
less  circular,  and  with  sharply  cut  edges,  involve  the  whole  thickness 
of  the  mucosa,  and  may  be  associated  with  a  similar  condition  through- 
out almost  the  entire  colon.  In  some  cases  the  condition  seems  to 
have  a  relationship  to  chronic  renal  disease.  It  probably  plays  no 
part  in  the  etiology  of  chronic  rectal  ulceration. 

Chronic  diffuse  ulceration. — Excluding  tuberculous  disease, 
where  the  diagnosis  is  made  upon  bacteriological  or  pathological 
grounds,  most  cases  of  chronic  diffuse  ulceration  are  of  obscure 
origin.  Whatever  be  the  prime  cause,  the  common  organisms  of  sup- 
puration, viz.  streptococci,  staphylococci,  and  the  Bacillus  coli,  are  in 
great  part  responsible  for  the  spread  and  ehronicity  of  the  ulceration. 
Hence  it  is  that  some  put  forward  syphilis  as  a  primary  cause,  others 
maintain  that  chancroid  is  more  often  responsible  than  syphilis,  some 
think  that  gonorrhoea  may  be  the  initial  lesion,  and  others  maintain 
with  very  good  reason  that  some  form  of  injury,  particularly  injury 
to  the  rectal  wall  during  labour,  is  the  most  important  cause. 
It  is  certain  that  women  are  more  often  affected  than  men,  and 
a  reference  to  these  causes  will  show  how  much  more  frequently 
the  female  sex  is  predisposed. 

Symptoms  of  chronic  diffuse  ulceration.— Whatever  the 
cause,  the  symptoms  are  characteristic.  The  accumulation  of  the  dis- 
charges in  the  lower  bowel  creates  a  frequent  reflex  desire  to  defsecate. 
Since  the  lower  bow-el  contains  scarcely  any  faecal  material, 
little  but  flatus,  mucus,  pus,  and  perhaps  blood,  is  passed.  This 
frequency  of  defgecation  is  particularly  present  in  the  early  morning 
immediately  the  patient  assumes  the  upright  position,  or  at  any  other 


700 


RECTUM   AND   ANAL   CANAL 


% 


time  during  the  day  after  resting  for  a  while.     The   remainder  of 
the  day  the  patient  may  spend  in  comparative  comfort.     But  as  the 

ulceration  progresses  and 
the  discharges  become  more 
copious  the  desire  to  go  to 
stool  will  be  felt  more 
and  more  frequently  during 
the  day,  until  it  may  be 
that  a  call  must  be  answered 
every  hour.  The  quantity 
of  pus  and  blood  passed 
will  vary  considerably,  de- 
pending upon  the  extent 
and  depth  of  the  ulceration. 
Pain  is  not  a  marked  fea- 
ture in  the  early  stages, 
but  later  some  pain  in  the 
perineum,  in  the  back,  or 
radiating  down  the  thighs 
is  very  common.  Reflex 
urinary  symptoms  may  be 
present. 

A  progressive  loss  of 
weight  and  strength  due 
to  the  continual  discharges, 
the  loss  of  appetite  and 
insufficiency  of  food,  and 
the  unhealthy  fife  which 
has  to  be  led  by  these 
sufferers,  will  certainly  be 
present  sooner  or  later. 
In  a  considerable  number 
of  cases  some  narrowing 
of  the  lumen  of  the  bowel 
will  occur,  and  the  symp- 
toms of  chronic  intestinal 
obstruction  add  to  the 
suffering  and  malnutrition 
of  the  patients.  Perirectal 
suppuration  is  common. 
Distant  foci  of  inflamma- 
tion, particularly  involving 
they   may  in   any   infective 


Fig.  503. — Extensive  ulceration  of  the  rec- 
tum, reaching  from  the  anus  (which  is 
surrounded  with  piles)  to  some  6  inches 
above.  The  walls  of  the  bowel  are 
considerably  thickened,  and  several 
perforations  are  seen.  The  cause  was 
supposed  to  be  syphilis. 

the    joints,    not    infrequently   occur,  as 
disease. 


ULCERATION 


701 


Th<'  ulceration  in  Borne  cases  extends  to  the  pelvic  colon,  and  over 
this  viscus  pain  may  be  experienced  and  tenderness  elicited.  The 
pelvic  and  iliac  colons  may  be  felt  as  thickened  cylinders.  Plastic 
peritonitis  is  commonly  present,  and  localized  suppuration  or  diffuse 
peritonitis  may  occur  either  from  perforation  of  an  ulcer  or  migration 
of  the  bacteria  through  the  unhealthy  bowel  wall. 

On  examination  with 
sigmoidoscope  the 
diagnosis  is  easy,  but 
of  the  ulcera- 
tion often  remains  un- 
determined. The  sig- 
moidoscope may  fail  to 
demonstrate  the  upper 
limit  of  the  disease, 
either  because  its  pas- 
sage is  prevented  by  a 
stricture  or  because  its 
length  is  insufficient.  In 
such  cases  the  extent  of 
bowel  involvement  can 
only  be  decided  by  ab- 
dominal exploration. 

Treatment  of 
ulceration  of  the 
rectum  and  anal 
canal.  —  This  depends 
to  a  slight  extent  upon 
the  cause,  but  far  more 
upon  the  situation  and 
extent,  of  the  ulceration. 
If  it  be  due  to  a  specific 
organism,  the  recognized 
treatment  of  this,  either 
by  drugs  or  by  vaccines, 
is  indicated.     Such  cases 

form  a  small  minority,  for  when  cases  are  first  seen  the  ulceration 
has  become  chronic,  and  is  in  great  part  dependent  upon  the  common 
pyogenetic  bacteria  ;  the  infection  is  a  mixed  one,  and  vaccines  are 
probably  useless.  In  all  cases  absolute  rest  in  bed  is  essential,  tin- 
diet  should  be  very  light  and  calculated  to  leave  the  smallest  possible 
residue,  and  the  bowels  should  be  carefully  regulated  by  aperients  to 
prevent  accumulation  of  faecal  material  in  the  rectum. 

When  the  ulceration  involves  the  anal  canal  only,  or  at  the  most 


Fig. 


504. — Extensive  ulceration   of  the 
rectum,  of  unknown  origin. 


7oa  RECTUM   AND  ANAL   CANAL 

the  lower  rectum,  the  sphincters  are  to  be  stretched  under  anaesthesia, 
and  some  application  made  direct  to  the  ulcerated  surface.  Nitric- 
acid,  carbolic  acid,  or  other  strong  caustic  may  be  applied.  Or  the 
ulcer  may  be  curetted  and  covered  with  some  antiseptic  powder,  such 
as  iodoform.  Hot  hip-baths  and  enemata  containing  some  antiseptic, 
such  as  perchloride  of  mercury,  or  chinosol,  should  be  given  daily. 
The  application  of  the  caustic  may  have  to  be  repeated.  Such  treat- 
ment may  succeed  in  early  cases  where  ulceration  is  of  very  limited 
extent. 

When,  however,  the  ulceration  is  higher  in  the  bowel,  but  still  of 
limited  extent,  similar  treatment  may  be  employed,  but  is  very  often 
attended  with  complete  failure.  In  fact,  rectal  ulceration  which  is 
at  all  extensive  and  long  continued  is  very  rarely  cured  by  enemata 
or  direct  applications. 

Zinc  cataphoresis. — The  principle  of  this  treatment,  according 
to  Ironside  Bruce,  "  is  that  zinc  sulphate  is  broken  up  by  the  galvanic 
current,  the  zinc  ions  travel  towards  the  negative  pole,  and  are  thus 
driven  into  the  tissues  surrounding  the  positive  pole.  The  SOt  so 
liberated  combines  with  the  metallic  zinc  of  the  positive  pole  to  form 
again  zinc  sulphate.  The  method  of  application  is  exceedingly  simple. 
The  necessary  apparatus  is  as  follows  :  A  zinc  rod,  6  in.  in  length,  with 
suitable  connexion  at  the  end  for  the  purpose  of  attaching  it  to  the 
positive  pole  of  a  galvanic  supply  ;  a  large  indifferent  electrode  to 
connect  the  negative  pole.  The  zinc  rod  is  covered  with  four  layers 
of  lint,  which  is  saturated  with  a  4  per  cent,  solution  of  zinc  sulphate 
(in  distilled  water).  The  negative  electrode  is  soaked  in  plain  water 
to  ensure  a  good  contact.  The  patient  being  suitably  placed,  lying  on 
the  side,  with  the  aid  of  a  little  vaseline  as  a  lubricant  the  positive  pole 
is  introduced  in  the  rectum  to  a  distance  well  above  the  ulcerated  area. 
The  indifferent  electrode  is  placed  over  the  sacrum  or  on  the  abdomen  ; 
to  this  is  attached  the  negative  pole  of  the  source  of  the  galvanic 
current,  the  positive  pole  being  attached  to  the  zinc  rod.  It  is  .necessary 
to  have  a  milliamperemeter  in  circuit.  All  connexions  having  been 
made  secure,  the  circuit  is  completed,  and  the  resistance  cut  out  until 
the  meter  stands  at  20  ma.  Li  one  or  two  minutes  the  amount  of 
current  will  increase  to  25-30  ma.,  and  it  is  kept  at  this  figure  for  ten 
minutes.  Such  an  application  is  made  once  every  two  Aveeks.  This 
method  is  quite  sufficient  where  the  ulceration  is  confined  to  the  lower 
portion  of  the  bowel,  but  where  the  disease  extends  higher  up,  slightly 
more  complicated  apparatus  is  necessary."' 

This  treatment,  although  of  comparatively  recent  date,  seems 
worthy  of  a  thorough  trial.  Should  it  fail,  operative  measures  have 
to  be  considered. 

Excision  of  the  diseased  bowel  would  seem  to  be  the  ideal  method 


RKCTAL  ULCKRATION  :  TREATMENT 

of  treatment.  Superficial  ulcers  <>f  comparatively  small  size  may  be 
excised  and  the  margins  of  the  mucosa  sutured.    If  the  ulceration  is 

superficial  and  involves  only  the  anal  canal,  or  at  most  the  lower  inch 
oftherectuni.it  maybe  possible  to  excise  the  diseased  mucosa — White- 
head's operation  (p.  680).  This  operation  has,  however,  a  very  limited 
sphere  of  practicability,  as  ulceration  in  this  region  generally  responds 
to  more  simple  methods  of  treatment.  It  must  be  insisted  that  all 
the  diseased  mucosa  should  be  removed  and  healthy  mucosa  sutured 
to  the  skin  of  the  anal  margin,  or  success  cannot  be  anticipated. 

When  ulceration  involves  the  higher  bowel  and  extends  more  deeply, 
the  rectum  in  whole  or  in  part  may  be  excised  by  a  method  similar 
to  that  for  excision  of  a  cancerous  rectum,  save  that  the  perirectal 
tissues  need  not  be  removed  (p.  721).  Should  the  ulceration  extend 
to  the  pelvic  colon  (as  determined  by  laparotomy),  excision  is  still 
possible  by  the  combined  abdomino-pft-ineal  operation  (p.  723). 
Excision  is  only  practicable  when  the  whole  diseased  area  can  be 
removed,  the  sphincter  muscle  and  its  nerve  supply  preserved,  and 
healthy  bowel  sutured  to  healthy  bowel  or  to  the  skin  of  the  anal 
margin  without  undue  tension.  It  is  contra-indicated  when  perirectal 
suppuration,  sinuses,  and  fistulas  are  present.  At  all  times  it  is  a 
serious  operation,  and  one  not  to  be  lightly  undertaken.  Its  severity 
is  increased  in  the  enfeebled  subjects  of  chronic  ulceration,  and  the 
difficulties  of  the  operation  are  magnified  by  the  perirectal  infiltration 
which  is  often  present. 

Colostomy  is  merely  a  palliative  operation,  whose  object,  by 
diverting  the  passage  of  faeces,  is  to  give  entire  rest  to  the  diseased 
bowel.  It  is  the  only  procedure  in  many  cases  where  perirectal  sup- 
puration, sinuses,  and  fistulas  are  present.  Where  excision  is  impossible, 
either  from  the  general  condition  of  the  patient  or  upon  anatomical 
grounds,  and  where  simpler  forms  of  treatment  have  failed  to  alleviate 
symptoms,  colostomy  is  indicated.  There  will  naturally  be  consider- 
able aversion  on  the  part  of  the  patient  to  the  operation,  but  his 
condition  is  often  enormously  improved  by  it,  and  his  life  rendered 
more  tolerable.  Following  the  operation,  energetic  treatment  locally 
must  be  persevered  with.  The  bowel  must  be  thoroughly  cleansed, 
and  this  may  be  more  effectually  done  through  the  colostomy  opening 
than  from  the  anus.  Should  the  ulceration  heal,  certainly  some  degree 
of  stricture  will  result.  If  this  can  be  effectually  treated  (p.  705)  it 
may  be  possible  to  close  the  colostomy  opening.  More  often  the 
colostomy  must  remain  permanently,  for,  when  the  ulceration  has 
been  so  extensive  as  to  warrant  colostomy,  in  the  healing  process  the 
bowel  becomes  so  deformed  that  the  satisfactory  treatment  of  the 
stricture  is  impossible,  and  its  covering  is  so  delicate  that  ulceration 
is  liable  to  recur  upon  the  slightest  provocation. 


;o4  RECTUM   AND   ANAL   CANAL 

STRICTURE 

The  lumen  of  the  rectum  may  be  narrowed  by  extrinsic  causes, 
e.g.  enlargements  of  the  prostate,  pelvic  cellulitis,  uterine  tumours, 
or  hydatid  cysts  of  the  pelvis,  which  are  all  described  in  their  appro- 
priate places.  A  stricture  implies  that  the  narrowing  is  produced  by 
some  abnormality  or  pathological  change  in  the  bowel  wall  itself. 

A  stricture  may  be  (1)  congenital  (p.  669) ;  (2)  spasmodic ;  (3)  the 
result  of  inflammatory  changes  in  the  bowel  wall.  Congenital  stricture 
is  not  very  common.  Although  the  condition  is  congenital  in  origin, 
symptoms  may  not  occur  until  later  life.  The  stricture  is  situated  in 
the  anal  canal  or  at  its  junction  with  the  rectum.  Spasmodic  stricture 
is  extremely  rare.  Inflammatory  changes  in  the  bowel  wall  may 
narrow  the  lumen  in  one  of  two  ways — (a)  by  a  diffuse  mucous,  sub- 
mucous, and  muscular  infiltration,  such  as  may  occur  in  the  localized 
gummata,  the  diffuse  ano-rectal  syphiloma  (p.  698),  and  to  some 
extent  in  diffuse  tuberculosis  of  the  bowel  (p.  696)  ;  (b)  much  more 
commonly  by  the  fibrous  contraction  which  necessarily  results  from  the 
healing  of  any  deep  and  extensive  ulceration  (p.  699).  Diffuse  inflam- 
matory infiltration  and  fibroid  contraction  may  occur  together. 

The  pathological  appearances  depend  upon  the  cause.  Con- 
genital strictures  are  felt  by  the  finger  as  a  tight  ring ;  postoperative 
strictures  in  the  anal  canal  are  felt  as  a  fibrous  ring  surrounding  the 
lumen  of  the  bowel ;  in  such  cases  there  is  no  deep  infiltration  of  the 
bowel  walls.  Where  fibrous  contraction  results  from  the  healing  of 
rectal  ulceration  the  degree  and  extent  of  the  stricture  will  vary 
enormously.  In  the  majority  of  cases  which  come  under  observation 
active  ulceration  is  still  present.  The  stricture  is  usually  within  reach 
of  the  examining  finger,  but  occasionally  it  is  higher,  and  may  be  at 
the  junction  of  the  rectum  and  the  pelvic  colon.  It  is  sometimes 
annular,  surrounding  the  lumen  as  a  fibrous  ring  ;  in  other  cases  the 
contraction  takes  place  on  one  side  only,  with  the  result  that  the  wall 
is  puckered  up  at  this  site  ;  again,  in  others  a  considerable  extent 
of  the  bowel  is  involved  in  the  contraction.  Polypoid  masses  of  in- 
filtrated mucous  and  submucous  tissue  may  be  seen  projecting  into 
the  rectum.  Haemorrhoids  frequently  accompany  a  stricture,  and  are 
probably  caused  by  the  pressure  upon  the  hemorrhoidal  veins.  The 
bowel  above  the  stricture  becomes  hypertrophied  and  dilated.  Fsecal 
masses  retained  above  a  stricture  will  cause  ulceration,  or  aggravate 
that  already  existing. 

Symptoms. — Most  commonly  the  symptoms  of  stricture  are 
slowly  engrafted  upon  those  of  ulceration.  The  passage  of  faeces 
becomes  increasingly  difficult  :  they  are  retained  above  the  stricture 
for  a  variable  time,  and  then  expelled  piecemeal,  so  that  the  motion 


RECTAL   STRICTURE  7°5 

consists  of  small,  hard,  isolated  fragments.    There  are  periods  of  days 

together  when  no  motion  may  be  passed.  If  the  Stricture  16  low  down. 
near  the  anal  margin,  e.g.  the  congenita]  stricture,  or  thai  following 

operations  upon  the  anal  canal,  the  motion  may  sometimes  be  flat- 
tened or  ribbon-shaped.  Tins  is  unusual  (p.  604).  Since  ulceration  is 
so  commonly  present,  the  passage  of  blood,  pus,  and  mucus  is  more  oi 

less  constant.  Even  if  ulceration  he  absent,  the  irritation  of  faeces 
retained  above  the  stricture  will  excite  a  catarrh  of  the  bowel,  shown 
by  the  passage  of  mucus,  and  perhaps  blood.  The  patients  complain 
of  diarrhoea — the  spurious  diarrhoea  of  proctitis  or  ulceration.  Sooner 
or  later,  symptoms  of  intestinal  obstruction  appear — i.e.  flatulent  dis- 
tension, probably  aggravated  by  food;  unpleasant  rumblings  of  wind  in 
the  bowels,  accompanied  by  colicky  peristaltic  pains;  and  an  increasing 
demand  for  purgatives  to  obtain  an  action  of  the  bowels.  Later,  if 
the  stricture  be  allowed  to  progress,  the  compensation  of  the  colon, 
taxed  to  its  utmost,  fails  :  distension  progresses,  and  the  obstruction 
terminates  acutely  or  subacutely  (p.  719).  The  colon,  rilled  with  the 
contents  of  the  small  bowel  and  its  own  secretion  and  gases,  is  distended 
so  greatly  that  its  circulation  is  impeded,  and  infection  of  its  walls 
results.  Local  infective  necrosis  of  its  wall  may  occur,  and  acute 
perforative  peritonitis  follow.  The  perforation  will  usually  be  low- 
in  the  pelvic  colon,  where  distension  is  greatest  and  bacterial  life  most 
rampant,  but  it  may  be,  as  in  any  case  of  colonic  obstruction,  in  the 
caecum. 

The  diagnosis  is  readily  made  by  digital  and,  if  necessary,  by 
careful  sigmoidoscopic  examination.  Occasionally  difficulty  may  arise 
in  differentiating  the  simple  from  the  malignant  stricture.  In  simple 
fibrous  contraction  there  cannot  be  doubt,  but  where  there  is  narrowing 
of  the  bowel  associated  with  irregular  poh-poid  masses  projecting  into 
its  lumen  the  similarity  to  cancer  is  sometimes  very  great.  In  the 
simple  disease  there  will  be  a  long  history  of  ulceration  of  the  bowel, 
probably  commencing  at  an  age  when  malignant  disease  is  unusual. 
The  polypoid  masses  have  not  the  characteristically  hard  and  irregular 
surface  of  a  carcinoma.  If  doubt  exists,  a  portion  of  the  edge  of  the 
thickening  should  be  submitted  to  microscopy. 

The  treatment  varies  with  the  site  and  extent  of  the  stricture, 
and  with  the  presence  or  absence  of  ulceration. 

Dilatation. — Strictures  situated  in  the  anal  canal,  e.g.  the  con- 
genital form  and  those  following  operations  upon  the  anal  canal,  may 
be  treated  satisfactorily  by  dilatation  with  Hegar's  dilators.  Before 
dilatation,  if  the  stricture  is  very  firm,  it  may  be  advisable  to  incise  it 
at  four  points  situated  at  the  extremities  of  two  diameters  at  right 
angles  to  one  another.  Dilatation  will  have  to  be  maintained  for 
some  time,  perhaps  during  the  rest  of  life.  Simple  strictures  of  the 
■2t 


706  RI-CTUM   AND   ANAL   CANAL 

lower  rectum,  say  the  last  inch,  may,  in  the  absence  of  ulceration,  be 
treated  in  the  same  manner.  Dilatation  of  a  stricture  higher  in  the 
rectum  is  often  a  difficult  matter,  but  in  the  absence  of  ulceration  a 
soft  rubber  dilator  may  be  passed  through  the  sigmoidoscope  tube  : 
a  stiff  metal  instrument  is  dangerous,  since  it  may  readily  perforate 
the  bowel  wall  and  cause  perirectal  inflammation. 

Complete  proctotomy. — The  bowel  and  tissues  posteriorly  are 
divided  completely  from  a  level  above  the  stricture  in  the  median  line, 
the  knife  emerging  at  the  tip  of  the  coccyx.  Strictures  associated  with 
ulceration  may  be  treated  in  this  manner.  Good  drainage  is  secured, 
threatened  obstruction  overcome,  and  ulceration  given  a  chance  to 
heal.  The  after-treatment  of  this  septic  wound  requires  unremitting 
care,  and  during  the  healing  contraction  will  occur,  and  constant 
dilatation  will  be  required.  Probably  several  weeks  or  even  months 
will  elapse  before  healing  is  complete.  Incontinence  of  faeces  is  present 
at  first,  but  is  generally  recovered  from  when  healing  is  complete. 

Excision. — In  strictures  of  the  anal  canal  which  do  not  respond 
to  dilatation,  Whitehead's  operation  may  be  performed.  This  may 
be  a  simple  operation  in  congenital  stricture,  but  in  postoperative 
strictures  the  scar  tissue  may  be  dense,  adherent  to  deeper  parts, 
and  difficult  to  dissect.  The  method  probably  has  a  very  limited 
practicability,   as  most  of  these  strictures  can  be  readily  dilated. 

In  higher-lying  strictures  the  affected  bowel  may  be  excised.  The 
principles  involved  are  similar  to  those  of  excision  of  an  ulcerated 
rectum  (p.  702).  The  excision  of  these  strictures  is  a  severe  and  difficult 
operation,  and  must  never  be  lightly  undertaken.  It  should  be  reserved, 
in  suitable  subjects,  for  high-lying  undilatable  or  ulcerated  strictures. 
In  some  measure,  excision  may  be  looked  upon  as  an  alternative  to 
complete  proctotomy.  If  successful,  its  advantages  are  the  shortened 
convalescence  and  the  restoration  of  the  lumen  of  the  bowel.  It  is, 
however,  a  much  more  severe  and  formidable  operation. 

Colostomy  may  be  necessary  to  relieve  urgent  obstruction.  It 
is  indicated  in  the  majority  of  cases  which  are  complicated  with 
perirectal  suppuration,  sinuses,  and  fistula?.  Patients  enfeebled  by  pro- 
longed ulceration  are  often  best  treated  by  colostomy,  for  they  are 
in  no  condition  to  stand  the  severe  operation  of  excision,  or  the  pro- 
longed suppuration  after  complete  proctotomy.  By  care  after  the 
operation,  the  ulceration  may  heal.  It  may  then  be  feasible  to 
dilate  the  stricture  or  possibly  to  excise  it.  Later  the  colostomy 
may  perhaps  be  closed  (p.   703). 

PROLAPSE 

Prolapse  may  be  defined  as  a  protrusion  through  the  anal  orifice 
of  parts  normally  situated  within.     It  may  be  partial  (Fig.  505),  when 


RECTAL   PROLAPSE 


707 


rectal  mucosa  alone  protrudes,  01  complete  (Fig.  506),  when  all  the 
ooats  of  the  bowel  project . 

Etiology. — The  condition  may  occur  at  any  age,  bul  is  peculiarly 
frequent  a1  the  extremes  oi  life,  babies  and  young  children  furnishing 

B  large  proportion  of  cases. 

Normally  during  defecation  a  narrow  ring  of  mucosa  protrudes 
from  the  amis,  and  recedes  immediately  after  the  completion  of  the 
act  ;  if  recession  does  not  immediately  occur,  prolapse  may  be  said 
to  be  present.  Any  swelling  of  this  ring  of  mucosa,  inflammatory  or 
otherwise,  predisposes  to  prolapse.  Such  swelling,  in  babies  and  young 
children,  may  be  due  to  the  irritation  of  worms,  but  probably  this 


Fig.  505. — Partial  prolapse,  only 
the  mucosa  involved. 


Fig.  506. — Complete  prolapse,  the 
whole  thickness  of  the  bowel 
wall  protruded. 


cause  has  been  much  exaggerated.  In  diarrhoea  the  mucosa  may  be 
swollen,  straining  is  severe  and  prolonged,  and  a  child  suffering  from 
this  affection  is  often  allowed  to  remain  seated  on  the  chamber  for 
an  indefinite  period,  thus  favouring  prolapse.  The  straining  due  to 
phimosis  or  to  vesical  calculus  is  often  held  responsible,  but  careful 
inquiry  shows  that  this  alone  plays  very  little,  if  any,  part  in  the 
etiology.  In  adults  similar  causes  may  be  prevalent,  but  much  more 
commonly  the  predisposing  cause  is  a  hsernorrhoidal  swelling  of  the 
mucosa  (p.  676).  In  elderly  subjects  haemorrhoids  may  be  present, 
but  at  this  age  the  straining  and  local  venous  engorgement  due  to 
urinary  trouble,  such  as  urethral  obstruction  from  enlargement  of  the 
prostate,  are  often  responsible. 

Once  partial  prolapse  is  established,  it  tends  to  be  progressive, 
unless  promptly  and  efficiently  treated.  The  sphincters  become 
stretched  and  partly  lose  tone,  thus  favouring  the  increase  of  the 
protrusion. 

Complete  prolapse  usually  results  from  a  neglected  partial  prolapse, 


7o8  RECTUM   AND   ANAL   CANAL 

and  generally  evolves  gradually,  but  occasionally  the  prolapse  may  be 
complete  and  well  developed  from  the  beginning. 

The  conditions  essential  for  complete  prolapse  are — (1)  stretching 
and  eventually  relaxation  of  the  supporting  tissues  of  the  rectum 
— the  pelvic  fascia,  and  the  fat  of  the  ischio-rectal  fossae  ;  (2)  a  long 
mesentery  to  the  pelvic  colon  ;   (3)  relaxation  of  the  sphincter  muscles. 

Complete  prolapse  is  practically  never  found  in  a  healthy  fat  baby. 
but  only  in  the  wasted  baby  with  loss  of  perirectal  fat.  It  is  especially 
seen  in  association  with  severe  diarrhoea,  or  with  some  specific  fevers, 
e.g.  measles  and  whooping-cough  ;  the  severe  cough  in  these  diseases 
■excites  the  formation  of  the  prolapse.  The  relatively  straighter  course 
of  the  child's  pelvis  predisposes  to  the  condition,  especially  if  defseca- 
tion  is  permitted  in  the  sitting  posture,  in  which  the  rectum  is  prac- 
tically a  straight  tube. 

In  adults  complete  prolapse  is  more  common  in  women  who 
have  borne  children,  due,  no  doubt,  to  a  laceration  of  some  of 
the  supporting  tissues  of  the  rectum  during  labour. 

In  elderly  subjects  a  partial  protrusion  is  liable  to  become  complete, 
for  at  this  age  the  absorption  of  fatty  tissues  supporting  the  rectum 
is  probable,  and  the  sphincters  easily  lose  tone. 

At  any  age  a  polypus  may  cause  prolapse,  partial  or  complete. 
Such  a  protrusion  is  more  of  the  nature  of  an  intussusception  than  a 
true  prolapse,  the  part  bearing  the  tumour  becoming  invaginated  into 
the  lower  rectum.  Intussusceptions  of  the  rectum  probably  do  not 
occur  in  the  absence  of  a  tumour. 

Clinical  manifestations. — The  appearances  are  quite  dis- 
tinctive. Projecting  from  the  anus  is  a  more  or  less  cylindrical 
mass  covered  with  mucosa,  and  varying  from  a  mere  ring  of  mucosa 
in  the  partial,  to  a  thick  cylinder  of  bowel,  5  or  6  in.  long,  in 
the  complete  variety.  In  the  smaller  protrusions  the  cylinder  is  more 
or  less  straight,  but  in  the  larger  it  is  slightly  curved.  The  mucosa 
may  have  a  normal  appearance  if  not  subjected  to  irritation,  and  if 
it  be  only  loosely  grasped  by  the  sphincter ;  but  when  irritated  or 
tightly  gripped,  it  becomes  of  a  dark-red  or  even  purple  colour.  In 
cases  which  have  been  allowed  to  protrude  for  some  time,  abrasions  of 
the  mucosa  may  occur,  and  in  some  ulceration  or  acute  infective 
gangrene  may  supervene.  In  others  considerable  thickening  of  the 
prolapsed  part  from  inflammatory  infiltration  into  the  mucous  and 
submucous  tissues  will  occur.  The  mucosa  in  the  larger  protrusions 
is  seen  to  be  arranged  in  parallel  and  concentric  folds,  and  the  orifice 
is  not  infrequently  more  or  less  occluded  by  one  of  these  folds. 

In  complete  prolapse  the  peritoneum  covering  the  anterior  surface 
of  the  rectum  will  be  drawn  down,  and  in  large  protrusions  it  must  pass 
through  the  anal  orifice  with  the  bowel.     A  hernial  sac  is  thus  con- 


RECTAL    PROLAPSE  7°9 

Btituted  which  may  or  may  nol  contain  an  abdominal  viscus.  In  a 
I'cu  cases  the  hernial  contents  have  been  known  to  protrude  at  1 1 1< ■ 
anal  orifice  in  £ron1  of  the  prolapsed  bowel,  which  is  displaced  posteriorly 
and  its  orifice  directed  backwards.  The  contents  are  naturally,  in  the 
greal  majority  of  cases,  small  intestine,  bui  the  ovaries  and  bladder 
have  been  Eound.  Occasionally,  adhesions  may  form,  rendering  the 
(•(intents  irreducible.  Attempts  at  reduction  in  such  eases  have 
sometimes  resulted  in  rupture  of  the  rectum  and  protrusion  of  the 
herniated  gut  through  the  rent. 

Diagnosis. —  The  only  protrusions  from  the  anus  which  may 
be  mistaken  for  prolapse  are  the  simple  polypus  (very  rarely  a  malignant 
neoplasm),  haemorrhoids,  and  an  intussusception.  A  polypus  is  easily 
recognized  by  its  pedicle,  alongside  which  the  finger  can  be  passed 
into  the  bowel.  Hemorrhoids  form  a  series  of  tumours  surrounding 
t  lie  anal  orifice1.  An  intussusception  may  at  times  cause  a  little  difficulty. 
In  a  pure  prolapse  the  mucosa  is  continuous  with  the  skin  at  the  anal 
margin  ;  or  at  times,  the  anal  canal  not  being  everted,  there  is  a  very 
shallow  recess  at  the  base  of  the  prolapse,  whereas  in  an  intussusception 
there  is  a  distinct  sulcus  into  which  the  finger  may  be  passed  freely  all 
around. 

Treatment. — Any  prolapse  should  be  immediately  replaced.  In 
order  to  do  this  the  child  should  be  laid  across  the  knee,  or  the 
adult  upon  the  left  side,  and  the  prolapse  well  oiled  and  firmly 
grasped  with  the  hand.  Gentle  pressure  in  the  majority  of  cases  will 
Mieceed  in  reduction.  The  part  protruded  last  is  the  apex,  and  this 
must  be  returned  first.  If  reduction  be  not  done  immediately,  inflam- 
matory changes  and  those  resulting  from  the  grip  of  the  sphincters  may 
produce  serious  consequences,  and  render  replacement  very  difficult 
or  impossible. 

Recurrence  must  be  prevented  by  removal  of  the  cause.  Thus,  in 
children,  diarrhoea  and  the  feeble  wasted  condition  must  receive  treat- 
ment, and,  above  all,  the  child  must  not  pass  the  motions  in  the  sitting 
posture,  but  must  assume  the  squatting  position  on  a  low  pan  ;  in 
this  position  the  lower  sacrum  and  coccyx  are  bent  and  the  rectum 
is  more  supported  than  in  the  sitting  posture.  In  children  this  line  of 
treatment  will  usually  cure  the  disease,  but  in  a  very  small  minority,  in 
spite  of  all  care,  the  prolapse  will  recur,  demanding  some  form  of 
operative  treatment.  In  adults  similar  lines  of  treatment  should  be 
instituted  in  the  first  place,  but  in  the  majority  of  these  no  cure  will 
result,  and  further  treatment  is  indicated. 

Numerous  pessaries  have  been  invented  to  prevent  prolapse,  but 
all  are  unsatisfactory,  and  should  only  be  employed  when  there  are 
special  contra -indications  to  operation. 

Many  and  varied  operative  procedures  have  been  performed  for 


710  RECTUM  AND   ANAL   CANAL 

prolapse  of   the  rectum,   among  which  the  following    may  be  men- 
tioned : — 

1.  Searing  the  mucous  membrane  with  the  actual  cautery. 
— This  is  applicable  where  the  prolapse  is  only  partial.  It  is  especially 
useful  in  children,  and  for  slight  cases  in  adults  where  there  is  no 
hsemorrhoidal  condition  of  the  mucosa.  The  object  of  the  cautery  is 
to  cause  limited  sloughing  of  the  mucosa,  and  thus  narrowing  of  its 
circumference,  and  also  to  promote  adhesions  of  the  mucosa  to  the 
muscular  coat.  With  the  bowrel  protruding,  the  point  of  the  Paquelin 
cautery  at  a  dull-red  heat  is  drawn  from  its  base  to  its  apex,  in  a  series 
of  radiating  lines.  In  healing,  cicatrices  will  contract  in  both  the 
longitudinal  and  the  transverse  direction.  A  second  application  may 
be  necessary. 

2.  Excision  of  the  mucous  membrane. — In  prolapse  of  slight 
degree,  and  particularly  in  children  in  whom  the  cautery  has  failed 
to  effect  a  cure,  V-shaped  portions  of  the  mucous  membrane  may  be 
excised.  It  will  generally  suffice  to  remove  two  such  pieces,  one 
anteriorly  and  the  other  posteriorly.  The  cut  edges  of  the  mucosa  are 
united  by  sutures.  The  extent  of  removal  depends  upon  the  propor- 
tions of  the  prolapse. 

The  whole  circumference  of  the  mucous  membrane  may  be  excised 
and  the  cut  edges  of  the  mucosa  united  to  those  of  the  skin — White- 
head's operation.  This  procedure  is  suitable  for  prolapse  caused  by  a 
haemorrhoidal  condition  of  the  mucosa  of  the  rectum,  for  any  partial 
prolapse,  and  for  some  cases  of  complete  prolapse  of  very  moderate 
degree.  In  the  latter  class,  when  the  mucosa  has  been  united  to  the 
skin  the  muscular  wall  of  the  bowel  will  be  folded,  and  adhesions  of 
the  mucosa  to  the  pleated  muscular  wall  will  prevent  a  further  ten- 
dency to  prolapse. 

3.  Excision  of  the  prolapsed  portion. — This  method  is  suitable 
for  all  cases  of  complete  prolapse.  It  is  attended  with  a  greater  risk 
and,  according  to  some,  a  less  promising  after-result  than  the  method 
described  next.  The  protrusion  is  covered  with  sterile  gauze  and 
drawn  well  down,  and  an  incision  is  made  about  f  in.  from  the  anal 
margin,  and  parallel  to  it,  into  the  prolapse.  This  will  in  all  probability 
be  below  the  level  of  the  internal  sphincter  muscle.  The  incision  is 
deepened  through  all  the  layers  of  the  gut  and  the  peritoneal  cavity 
opened.  When  this  is  done,  care  must  be  taken  to  avoid  injury  to  any 
herniated  intestine,  which,  if  present,  should  be  returned  into  the 
pelvic  cavity.  The  incision  should  then  be  carried  through  the  whole 
circumference  of  the  protruded  gut.  The  latter  may  now  be  unfolded, 
as  it  were,  by  pulling  the  cut  edge  of  mucosa  downwards  and  turning- 
it  inwards.  The  gut  can  then  be  drawn  taut  and  clamped  close  to 
the  anal  margin,  the  part  distal  to  the  clamp  being  cut  away.     AH 


RECTAL    PROLAPSE     ADENOMA  711 

haemorrhage  must  be  arrested.  The  edgea  of  the  proximal  portion  of 
the  gut  are  now  sutured  to  those  of  the  distal  portion  surrounding  the 
anal  margin.  The  patient  should  1"'  kepi  under  observation  for  some 
time,  for  fear  of  contraction  necessitating  dilatation. 

1.  Fixation  of  the  gut  within  the  abdomen. — This  procedure 
is  an  alternative  to  the  foregoing,  and  opinion  is  by  no  means  unani- 
mous as  to  which  operation  gives  the  better  results.    The  method  is, 

of  course,  only  applicable  to  cases  of  complete  prolapse.  Its  object 
is  to  anchor  the  pelvic  colon  within  the  abdomen,  and  so  long  as  the 
anchorage  remains  prolapse  cannot  recur. 

There  are  two  places  at  which  the  colon  may  be  fixed — (a)  the 
peritoneum  of  the  anterior  abdominal  wall  and  underlying  transversalia 
fascia,  and  (b)  the  iliac  fascia  and  peritoneum  of  the  iliac  fossa.  In 
either  case,  after  the  abdomen  is  opened  the  colon  is  drawn  upwards 
as  far  as  possible  and  fixed  in  this  taut  position  by  sutures.  In  the 
former  case  the  peritoneum  is  raised  from  the  anterior  abdominal  wall 
on  either  side  of  the  incision  and  its  two  edges  sutured  to  the  walls  of 
the  colon,  and  the  longitudinal  band  upon  the  latter  is  sewn  directly 
to  the  transversalis  fascia.  Thus  a  broad  surface  for  adhesion  is 
secured.  In  the  latter  case  the  principle  is  similar ;  the  peritoneum 
having  been  lifted  from  the  iliac  fossa,  the  bowel  is  sewn  to  the  iliac 
fascia,  and  the  peritoneum  to  the  walls  of  the  bowel.  In  all  probability 
this  gives  a  firmer  anchorage  than  the  former  method,  and  it  is  certainly 
less  likely  to  cause,  at  a  later  date,  intestinal  obstruction  or  pain  from 
the  dragging  of  the  adhesions,  both  of  which  have  been  known  to 
follow  the  anterior  fixation. 

BENIGN   TUMOURS 

Adenoma  of  the  Rectum 

Adenoma  of  the  rectum  is  common  in  childhood,  but  less  frequent 
in  later  life.  It  originates  in  the  mucosa,  at  first  is  sessile,  but  usually 
becomes  pedunculated  ;  it  forms  a  firm,  bright-red  swelling  with  a 
smooth  or  lobulated  surface.  It  is  composed  of  glandular  tissue  similar 
to  the  glands  of  Lieberkiihn ;  occasionally  it  may  undergo  cystie 
degeneration.  In  children  it  is  invariably  pedunculated,  and  rarely 
exceeds  the  size  of  a  cherry,  whereas  in  adults  it  is  relatively  more 
frequently  sessile,  and  may  attain  much  larger  dimensions  (Fig.  507). 
It  is  usually  single  in  the  child,  but  in  the  adult  it  is  relatively 
more  commonly  multiple  (Fig.  508).  In  children  the  adenoma  in- 
variably remains  a  simple  tumour,  but  in  later  life  it  by  no  means 
infrequently  becomes  malignant.  Many  instances  are  recorded  in 
which  the  removal  of  an  adenoma  by  cutting  through  the  base 
of  attachment  has    been    followed    by  a   malignant   growth.     Simple 


RECTUM   AND   ANAL   CANAL 


$ 


Fi 


g.  507.  —  Adenomatous 
polypi  from  a  child  and 
an  adult. 


Fig.  508. — Two  pedunculated  adenomas 


adenoma  and  carcinoma  may  be  present 
simultaneously. 

The  symptom  is  painless  haemor- 
rhage ;  sometimes  this  is  accompanied 
by  mucoid  discharge.  If  the  adenoma 
originate  low  in  the  rectum,  or  if  the 
pedicle  be  sufficiently  long,  the  polyp 
may  protrude  through  the  anus.  Rarely 
will  the  pedicle  become  gripped  by  the 
sphincters,  and  the  tumour  slough  off.  An 
adenoma  is  seldom  (probably  never  in  the 
child)  of  sufficient  size  to  cause  impedi- 
ment to  the  passage  of  faeces.  A  simple 
neoplasm  may  be  the  starting-point  _  of 
an  intussusception  of  the  rectum. 

Diagnosis. — When    the    tumour    is 
pedunculated  the  diagnosis  is  easy,  as  by 
digital  examination  the  pedicle  can  usually 
be    felt ;    if   the  tumour  be  high-lying    a 
sigmoidoscopic     examination 
will    always   reveal  the  true 
condition.     The  diagnosis  of 
a  sessile  adenoma  can  often 
only     be    made     by    micro- 
scopy. 

Treatment. — An  ade- 
noma should  always  be  re- 
moved. In  the  child  it  is 
sufficient  to  cut  it  off  after 
ligaturing,  cauterizing,  clamp- 
ing, or  twisting  the  pedicle. 
In  the  adult  similar  treat- 
ment will  suffice  for  an  ob- 
viously pedunculated  and 
undoubtedly  innocent  tu- 
mour. If  there  exist  any 
suspicion  of  malignant  dis- 
ease, the  base  of  attachment 
and  the  adjacent  mucosa 
should  be  removed,  and  sub- 
mitted to  microscopy;  and 
if  malignant  transformation 
be  found,  the  case  must  be 
treated  accordingly. 


RECTAL    PAPILLOMA 


7i3 


Papilloma  of  the 
Recti  m 
The  so-called  vil- 
lous tumour  of  the 
rectum  is  care  ;  it  re- 
sembles  the  villous 
tumour  of  the  blad- 
der  and    the    pelvis 

of  the  kidney,  and 
consists  of  a  lobu- 
lated  spongy  mass, 
sessile  or  peduncu- 
lated, with  long  vil- 
lous tufts  studding 
its  surface  ;  these 
tufts  are  composed 
of  mucous  membrane 
and  are  very  vas- 
cular (Fig.  510).    The 


■<S 


<t 


flP 


Fig.  509. — Section  of  rectal  adenoma. 


ir 


villous      tumour     is 

confined  to  adult  life,  and   is  very  liable   to   become   malignant 
may  be  single  or  multiple  ;  if  pedunculated  it  always  lias  a  short  and 
broad  pedicle.      The 


symptoms       a  r  e 

haemorrhage  and  a 
glairy  white  dis- 
charge winch  seems 
characteristic.  Oc- 
casionally the  tu- 
mour may  protrude 
through  the  anus, 
or  portions  may  be- 
come detached  and 
be  passed  in  the 
motions.  The 
treatment  is  al- 
ways removal.  The 
tumour,  the  pedicle 
if  present,  and  the 
adjacent  mucosa 
should  be  removed, 
the  edges  of  the 
mucosa  being  su- 
tured. Microscopical 


Fig.  510. — Section  of  rectal  papilloma. 


714  RECTUM   AND  ANAL   CANAL 

examination  is  essential,  and  if  malignant  transformation  lias  taken 
place  the  case  must  be  treated  accordingly. 

Papilloma  of  the  Anus 

Papillomatous  masses  occasionally  arise  in  the  anal  canal,  or  in 
the  skin  immediately  surrounding  the  anus.  They  are  typical  papil- 
lomas, covered  with  squamous  epithelium.  They  resemble  the  venereal 
warts  of  the  genitals,  and  are  probably  always  caused  by  the  irritation 
of  discharges,  either  from  the  genitals  or  from  the  rectum.  These 
warts  must  be  treated  by  attention  to  their  causes,  strict  cleanliness 
and  the  application  of  a  dry  powder.  If  no  improvement  follows,  they 
may  be  removed  by  the  knife  or  by  the  application  of  carbonic 
dioxide  snow. 

Fibroma 

Swellings  consisting  of  fibrous  tissue  are  frequently  seen  in  the 
rectum  and  anal  canal,  but  the  majority  of  these  are  not  tumours 
in  the  true  sense  of  the  word  ;  they  are  inflammatory  in  origin. 
Occasionally  a  true  fibroma  occurs  ;  it  may  be  single  or  multiple,  sessile 
or  pedunculated,  and  is  usually  of  small  size,  although  a  few  instances 
are  recorded  in  which  the  tumour  reached  large  proportions.  Mixed 
fibromas,  such  as  fibro-myoma  and  fibro-myxoma,  have  been  recorded 
but  are  very  rare.     The  symptoms  are  similar  to  those  of  adenoma. 

Lipoma  of  the  Rectum 

Rectal  lipoma  is  rare  ;  in  many  of  the  cases  recorded  as  such  the 
tumours  really  originated  in  the  pelvic  colon  either  as  submucous  or 
subserous  growths  ;  when  the  latter,  the  pedicle  has  contained  a  pro- 
trusion of  peritoneum — a  point  to  bear  in  mind  when  operating  upon 
these  tumours  through  the  rectum.  The  symptoms  are  very  indefinite. 
If  large,  lipomas  may  cause  obstruction  ;  they  have  been  known  to 
become  extruded  and  cast  off. 

Vascular  ncevi,  lymphomas,  and  tumours  consisting  in  part  of  bone 
and  cartilage  have  been  described  as  occurring  in  the  rectum,  but  they 
are  all  exceedingly  rare. 

MALIGNANT    TUMOURS 

Sarcoma  of  the  Rectum 

Rare  anywhere  in  the  intestinal  tract,  sarcoma  attacks  the  rectum 
slightly  more  frequently  than  the  bowel  above.  It  affects  the  two 
sexes  equally  ;  it  has  usually  been  recorded  in  middle-aged  or  elderly 
subjects. 

All  types  of  sarcoma  have  been  recorded — round-celled,  spindle- 
celled,  alveolar,  lympho-,  and  melanotic.      The  spindle-celled   is   the 


MALIGNANT    DISEASE    OF    RECTUM  715 

most  Erequenl  variety.  The  growth  usually  originates  in  the  sub- 
mucosa,  bul  is  said  to  commence  sometimes  in  the  muscular  wall. 
h  forms  a  sessile  mass  projecting  into  the  Lumen  of  the  bowel; 
occasionally  it  may  become  more  or  lesa  pedunculated,  and  has  been 
known  to  prolapse  during  defalcation.  It  may  involve  only  a  limited 
portion  of  the  rectum,  but  occasionally  tends  to  grow  extensively 
botli  circumferentially  and  vertically,  clinically  resembling  chronic 
inflammatory  conditions,  for  which  it  has  not  infrequently  been  mis- 
taken. The  mucosa  covering  a  sarcoma  may  sooner  or  later  ulcer 
The  growth  tends  to  invade  parts  surrounding  the  bowel ;  glandular 
involvement  is  not  uncommon,  but  visceral  deposits  arc  rare. 

The  melanotic  variety  has  usually  occurred  at   the  anus,  but   has 
been  seen  also  in  the  rectum.     It  is  very  malignant,  visceral  depc 
occurring  early. 

The  symptoms  are  similar  to  those  of  carcinoma  (p.  718). 
The  lumen  of  the  bowel  is,  however,  less  encroached  upon,  and  the 
obstruction  less  marked. 

Diagnosis. — A  sarcoma  has  to  be  differentiated  from  carcinoma, 
from  chronic  inflammatory  affections,  and,  from  the  diffuse  ano-rectal 
syphiloma.  In  the  early  stages  its  submucous  position  will  distinguish 
it  from  carcinoma,  but  later,  when  ulceration  is  present,  clinical  diag- 
nosis may  be  impossible.  Similarly,  differentiation  between  an  ulcerating 
sarcoma  and  chronic  inflammatory  ulceration  may  be  clinically  impos- 
sible, and  even  extremely  difficult  microscopically. 

The  treatment  is  similar  to  that  of  carcinoma  (p.  720).  The 
ultimate  prognosis  is  bad,  recurrence  nearly  always  taking  place 
shortly  after  removal. 

Carcinoma   of   the    Rectum1 

A  carcinoma  may  originate  in  the  rectum,  the  anal  canal,  or  the 

skin  at  the  verge  of  the  anus.    About  3  per  cent,  of  primary  cancers 

occur  in  the  rectum.     Carcinoma  is  four  or  five  times  as  frequent  in 

_fhe  rectum  as  ejsewhere  in  the  intestine.     Cancel1  of  the  anal  canal  is 

much  less  common . 

Carcinoma  of  the  rectum  occurs  most  frequently  between  40  and 
60  years  of  age.  Youth  is  not  exempt ;  the  youngest  patient  in  mi- 
series was  13.  The  younger  the  patient,  the  more  rapid  and  malignant 
the  growth. 

The  growth  is  nearly  always  single.  A  few  cases  are  recorded  in 
which  two  primary  growths  were  present  in  the  rectum,  and  rarely 
two  primary  growths  have  been  reported,  of  which  one  was  in  the 
rectum  and  one  elsewhere.  The  tumour  may  originate  in  any  part, 
but  a  common  starting-point  is  low  down,  within  reach  of  the  finger; 

1  See  also  Vol.  I.,  p.  533. 


-i6 


RECTUM   AND   ANAL   CANAL 


— ^fl^ 


another    favourite    site    is   at   the   junction   with    the  pelvic   colon. 
Pigs.  511,  512,  513,  and  514  illustrate  different  appearances  of  cancer 

in  different  parts  of  the 
rectum. 

Pathology.  —  The 
growth  is  columnar- 
celled  (Fig.  515),  and 
originates  in  the  glands 
of  the  mucosa.  It 
spreads  by  (1)  direct 
extension,  (2)  the  lym- 
phatic channels,  and  (3) 
the  blood  stream. 

1.  Direct  exten- 
sion.— The  vertical  and 
circumferential  extent 
of  rectal  cancer  varies 
greatly.  When  first  seen, 
it  may  be  a  small  nodule 
involving  a  very  limited 
surface  of  the  bowel 
wall ;  in  other  cases  it 
may  have  surrounded 
the  entire  bowel  —  the 
annular  type.  Between 
these  two  all  possible 
varieties  exist. 

The  growth,  origin- 
ating in  the  mucosa, 
early  invades  the  mus- 
cular coats  (Fig.  516), 
and  sooner  or  later  the 
perirectal  tissues.  Thus 
the  tissues  of  the  ischio- 
rectal fossae  may  be  in- 
vaded, the  presacral  and 
precoccygeal  tissues  may 
be  infiltrated,  and  the 
growth  may  become 
fixed  to  the  pelvic  walls 
and  invade  nerve  trunks  ;  the  bladder,  prostate,  and  seminal  vesicles, 
or  uterus  and  vagina,  according  to  sex,  may  be  infected,  and  in  high- 
lying  growths  the  peritoneum  may  be  involved.  Rarely  the  growth 
extends  down  the  anal  canal,  and  may  protrude  at  the  anus.     There 


Fig.  511. — Cancer  of  rectum. 


RECTAL    CARCINOMA 


717 


Fig.  512. — Cancer  of  rectum. 


is  evidence  t<»  show  that 
in  some  oases  cancel  oells 
extend  in  the  submucous 
tissues  Ear  beyond  the 
naked-eye  limits  of  the 
growth. 

2.  Lymphatic  spread. 
— The  lymphatic  vessels 
of  the  rectum  accompany 
the  hemorrhoidal  veins, 
and  pass  backwards  and 
upwards  to  the  pararectal 
glands,  which  lie  in  close 
connexion  with  the  lateral 
and  posterior  surfaces  of 
the  bowel  from  just  above 
the  attachment  of  the 
levator  ani  muscle  to  the 
upper  limits  of  the  rec- 
tum. Their  efferent  ves- 
sels accompany  the  veins 
in   the   pelvic    mesocolon, 

and  enter  glands  adjacent  to  the  superior  hemorrhoidal  vessels. 
lowermost  of  these  glands  are  situated  immediately  in  front  of 

sacral  hollow,   but   higher  

up   as   the   mesentery  in-  ~~*- 

•creases  in  length  they 
become  farther  removed 
from  the  sacrum,  whilst 
at  the  upper  limit  they 
are  not  far  distant  from 
the  pelvic  brim,  and  in 
some  cases  may  communi- 
cate with  the  glands  along 
the  iliac  vessels.  Efferent 
vessels  from  these  enter 
glands  situated  around 
the  inferior  mesenteric 
vessels,  which  are  prac- 
tically continuous  with  the 
lumbar  glands.  Experi- 
mental injection  of  the 
lymphatics  of  the  rectum 
shows  that  in  some  cases  Fig.  513. — Cancer  of  rectum. 


The 
the 


7i8 


RECTUM   AND   ANAL   CANAL 


those  from  the  lower  portion  of  the  bowel  may  pass  to  the  oblique 
inguinal  glands.  This,  however,  is  not  confirmed  by  clinical  expe- 
rience, since  these  glands  are  not  invaded  by  a  rectal  cancer. 

A  rectal  cancer  may  involve  any  or  all  of  these  glands.      The 

duration  and  extent  of  the 
cancer  is  no  criterion  of 
the  extent  of  the  glandular 
involvement.  In  a  com- 
paratively small  primary 
growth  extensive  glandular 
involvement  may  be  pre- 
sent, and  vice  versa. 

Enlarged  glands  in  as- 
sociation with  cancer  of  the 
bowel  are  not  necessarily 
cancerous.  There  is  always 
the  possibility  of  mere 
septic  absorption  from  the 
ulcerating  growth. 

3.  Spread  by  the 
blood  stream. — We  are 
entirely  ignorant  of  the 
processes  which  govern  the 
spread  of  cancer  by  this 
route.  Visceral  metastases 
are  not  necessarily  a  late 
occurrence.  We  have  in- 
sufficient data  to  judge  of 
their  frequency ;  in  fifty 
consecutive  autopsies  upon 
persons  dying  from  the 
disease,  at  very  varying 
intervals  after  the  appear- 
ance of  symptoms,  I  found 
metastases  were  recorded 
in  seven  only.  In  all  the 
liver  Avas  involved,  and  in 
one  the  spleen.  In  three, 
secondary  growths  were  scattered  over  the  peritoneum,  but  possibly 
in  these  the  spread  was  by  the  lymphatics. 

Symptoms. — The  typical  symptoms  are  those  of  ulceration  com- 
bined with  stricture  (see  pp.  699  and  704).  In  intensity  each  symptom 
varies  within  wide  limits.  Haemorrhage  and  the  teasing  diarrhoea  may 
be  absent  for  some  time  ;    clinical  evidence  of  material  narrowing  of 


514. — Cancer  of  rectum. 


RECTAL   CARCINOMA 


719 


Hi  m 


tin'  lumen  of  the  bowel  may  !»'  long  delayed,  and  indeed  in  a  few  ca 

1  In'  disease  may  ran  its  course  without  symptoms  of  obstruction 
appealing;  in  others  again,  symptoms  of  obstruction  may  be  the 
initial  manifestation,  and  in  such  the  disease  has  advanced  insidiously 
and  assumed  large  proportions  without  symptoms  of  rectal  ulceration. 

If  untreated,  rectal  carcinoma  leads  to  a  fatal  issue  in  about  one 
and  a  half  to  two  years  on  the  average.  Not  infrequently  life  is  ter- 
minated by  acute  intestinal  obstruction,  arising  in  various  ways. 
Mosl  commonly  the 
bowel  above  the  con- 
striction becomes  ex- 
hausted, and  the  colon 
progressively  dilates. 
Occasionally  the  dis- 
tended pelvic  colon  may 
undergo  torsion  around 
its  mesenteric  axis.  In 
any  obstruction  of  the 
large  bowel  the  caecum 
may  be  the  most  dis- 
tended part,  and  occa- 
sionally an  acute  dila- 
tation of  the  caecum 
may  be  the  initial  evi- 
dence of  failing  com- 
pensation. Should  such 
a  caecum  have  retained 
its  original  peritoneal 
relationships,  and  be 
suspended  by  a  mesen- 
tery, a  volvulus  around 
its  mesenteric  axis  may 
occur.  Rarely  the  dis- 
eased part  becomes  in- 
tussuscepted    into    the 

lower  bowel.  Very  infrequently  the  small  lumen  left  by  the  invad- 
ing growth  may  be  occluded  by  a  faecal  mass  or  foreign  body,  such 
as  cherry-  or  plum-stones. 

In  a  few  cases  peritonitis  may  cause  death.  Bowel  distended  by 
mechanical  obstruction  is  predisposed,  partly  by  virtue  of  its  impeded 
circulation,  to  infection.  In  cancer  of  the  rectum  the  pelvic  colon  or 
caecum  may  thus  become  acutely  infected,  and  necrosis  of  the  walls 
may  result,  with  local  or  diffused  peritonitis,  which  is  practically 
always  fatal. 


So 

t: 

It 
SB 

v.; 

n 


•*'-*-S-".i'.i.-.2 


Fig.  515. — Edge  of  a  malignant  ulcer 
rectum,  showing  typical  appearance 
columnar-celled  cancer. 


of 

of 


720 


RECTUM   AND   ANAL   CANAL 


In  the  absence  of  these  complications,  factors  which  aid  in  the 
fatal  termination  are  exhaustion  from  repeated  haemorrhages,  pain, 
especially  when  the  large  nerve  trunks  are  involved,  sleeplessness 
from  the  incessant  diarrhoea  and  pain,  and  absorption  of  toxins. 

Diagnosis. — It  should  be  a  cardinal  rule  thoroughly  to  examine 
every  case  presenting  the  slightest  symptom  of  rectal  trouble.  If  this 
rule  were  followed,  and  patients  encouraged  to  present  themselves 
on  the  first  evidence  of  rectal  disease,  cancer  would  generally  be  re- 
cognized without  difficulty  at  an  early  stage.     The  irregularly  hard 

growth  projecting  into 
,'•■:  *  , ,  the  lumen  of  the  bowel 


:•?''•»'  ,1./' 


is    quite 


3*.  'J/  Investigation 

■^  aesthesia  and 

h\W  *&•     V  sigmoidoscope 

Ml;  r^     Mm  necessarv. 

;'  J ,  ^ 


m 


"it: 


< '- -safe?8? .  *<*  * v  r^  *^gL^$* 


characteristic. 

under  an- 

with  the 

oscope   may   be 

necessary. 

Although  in  most 
cases  the  cancer  is 
typical  to  sight  and 
touch,  it  may  some- 
times be  confused  with 
other  diseases.  Chronic 
septic  and  tuberculous 
ulcerations,  especially 
when  associated  with 
polypoidal  masses  of 
swollen  and  cedematous 
mucosa,  are  apt  to  be 
mistaken  for  carcinoma. 
The  history,  the  flat 
and  comparatively  su- 
perficial ulcer,  and  the 
absence  of  induration  will  generally  serve  to  differentiate  these  con- 
ditions. If  any  doubt  remains,  a  portion  of  the  swelling  must  be 
submitted  to  microscopy  without  delay.  At  times  diagnosis  between 
a  benign  and  a  malignant  neoplasm  of  the  rectum  may  be  difficult 
(p.  712).  The  rare  sarcoma  may  usually  be  distinguished  by  noting 
that  it  is  a  submucous  rather  than  a  surface  growth. 

Treatment  of  removable  cancer. — A  growth  may  be 
considered  removable  when  confined  to  the  rectum  (to  determine 
this,  examination  under  anaesthesia  may  be  necessary),  when  invaded 
glands  are  operable  and  visceral  deposits  are  absent.  Exceptions 
naturally  occur.  For  instance,  slight  invasion  of  the  prostate  has  been 
successfully  dealt  with  by  ablating  a  portion  of  the  gland  ;    similarly. 


Fig.  516. — Section  of  rectal  cancer,  showing 
infiltration  of  the  muscular  wall. 


RECTAL  CARCINOMA  :   TREATMENT  721 

the  posterior  vagina]  wall,  and  indeed  the  uterus  is  a  few  chosen  1 

Have  1 11  successfully  removed  :    so  has  an  adherent  loop  of  small 

intestine.  Fixation  to  the  bony  pelvis  contra-indicates  operation, 
l>ut  invasion  of  the  perirectal  cellular  tissue  does  not  necessarily  do  so. 
Each  case  rnusl  be  judged  upon  its  own  merits,  and  the  age  and  general 
condition  of  the  patient  must  be  fully  considered.  X<>  attempt  at 
removal  must  be  made  during  the  phase  of  acute  obstruction. 

The  principle  to  be  observed  in  operation  is  that  the  primary 
growth  and  the  lymphatic  drain  (whether  there  be  obvious  invasion 
or  not)  must  be  removed  in  continuity,  for  if  this  be  interrupted 
the  wound  may  become  infected  with  cancer  cells.  It  is  obvious  that 
the  perirectal  cellular  tissue,  including  the  pararectal  glands,  and  the 
bery  of  the  pelvic  colon,  including  the  glands  along  the  hemor- 
rhoidal vessels,  must  be  removed. 

The  operations  may  be  classified  under  two  headings,  according  to 
whether  the  growth  is  removed  (1)  entirely  from  the  perineal  aspect, 
or  (2)  partly  through  the  abdomen  and  partly  through  the  perineum — 
the  combined  abdomi no- perineal  operation. 

1.  Perinea!  approach. — There  are  two  methods  of  perineal 
approach — (a)  through  the  true  perineum,  and  (b)  from  behind,  after 
removing  the  coccyx,  and  as  much  of  the  sacrum  as  is  necessary. 

(a)  Removal  through  the  true  perineum. — By  dissection  from  the 
perineum,  the  rectum  is  severed  from  its  connexions,  and  the  upper 
rectum  or  pelvic  colon  drawn  through  the  perineal  wound  and  sutured 
to  the  skin.  In  order  to  mobilize  the  rectum  sufficiently  to  permit 
approximation  to  the  perineum  without  undue  tension,  it  is  necessary 
to  sever  the  muscular  (levatores  ani),  the  fascial  (visceral  prolongations 
of  the  pelvic  fascia),  the  peritoneal  (the  peritoneum  of  the  recto-vesical 
or  recto-vaginal  pouch)  and  the  vascular  (branches  of  the  superior 
hemorrhoidal  vessels)  connexions.  The  lower  pelvic  mesocolon  must 
also  often  be  divided. 

An  endeavour  may  be  made  to  preserve  the  external  sphincter  by 
commencing  the  incision,  after  thoroughly  stretching  the  muscle,  at 
the  muco-cutaneous  junction,  raising  the  mucous  membrane  as  in 
Whitehead's  operation,  and  deepening  the  dissection  into  the  perirectal 
tissues  at  the  upper  level  of  the  sphincter.  Owing  to  the  limited  space 
this  attempt  often  fails,  and  the  great  stretching  and  possibly  tearing 
necessitated  may  render  the  muscle  impotent.  Only  very  limited 
dissection  is  possible  by  this  route. 

When-  no  effort  is  made  to  preserve  the  sphincter  the  incision 
encircles  the  anus  and  is  prolonged  anteriorly  and  posteriorly  in  the 
mid-line.  Through  this  wound  a  much  more  thorough  dissection  may 
be  performed. 

(b)  Exposure  of  the  rectum  from  behind. — Kraske  introduced    this 


722  RECTUM   AND   ANAL   CANAL 

route  for  high-lying  growths,  and,  although  the  operation  has  been 
modified  by  many  surgeons,  it  still  bears  his  name.    The  bone  is  exposed 
by  a  median  or  slightly  left  lateral  incision  terminating  a  little  behind 
the  anus.    Some  surgeons  remove  the  coccyx  only,  others  a  piece  of  the 
left  border  of  the  sacrum,  others  (following  Rydygier)  turn  back  a  flap 
of  the  s;icrum  and  coccyx,  which  is  replaced  at  the  close  of  the  opera- 
tion.   The  levatores  ani  are  divided  on  either  side,  the  rectum  separated 
by  blunt  dissection  with  as  much  of  the  perirectal  tissues  as  possible, 
the  peritoneal  cavity  opened,  and  the  pelvic  mesocolon  divided  piecemeal 
until  sufficient  bowel  has  been  freed  to  permit  approximation  of  the 
proposed  site  of  section  to  the  anal  margin  without  undue  tension. 
The  further  steps  are  modified  to  meet  the  requirements  of  the  case. 
When  the  colon  can  be  brought  well  down  to  the  anus  the  best  pro- 
cedure is  to  divide  the  rectum  just  above  the  internal  sphincter  muscle, 
and  the  bowel  above  at  a  point  which  will  allow  it  easily  to  reach 
the  anus  ;    the  mucous  membrane  of  the  anal  canal  is  removed,  the 
bowel  drawn  through  the  sphincteric  orifice  and  sutured  to  the  skin  of 
the  anal  margin.     If  some  extent  of  the  lower  bowel  is  healthy,  this 
may  be  left  and  the  upper  cut  end  anastomosed  to  it.     This  is  not  so 
good   a  method,  as  it  may  tempt  the  surgeon  to  encroach  too  near 
to  the  growth  ;    moreover,  the  stitches  nearly  always  give  way,  and 
faecal  extravasation  results,  followed  by  prolonged    suppuration  and 
probably  some  constriction.    Neither,  procedure  may    be    applicable, 
from  inability  to  free  the  upper  bowel  sufficiently.     In  such  case,  a 
perineal   anus   is   established.     The    many  attempts  that  have   been 
made,  by  means  of  various  treatments  of  the  bowel,  to  gain  some 
control  over  such  an  anus  have  been  uniformly  unsuccessful. 

The  main  arguments  against  all  operations  from  the  perineal  aspect 
are  these  :  (i)  The  branches  of  the  superior  hsemorrhoidal  vessels  are 
cut  close  to  the  bowel  wall,  that  is  on  the  distal  side  of  the  junction 
of  the  anastomotic  loop  between  the  lowest  sigmoid  and  superior 
hsemorrhoidal  arteries  ;  hence,  gangrene  of  the  transplanted  bowel  is 
liable  to  occur,  followed  by  prolonged  suppuration,  and  constriction. 
Similarly,  if  the  bowel  is  united  to  the  anal  skin  with  any  tension,  the 
sutures  give,  the  bowel  retracts,  and  a  stricture  results  in  the  healing 
process,  (ii)  Not  infrequently,  owing  to  the  fact  that  the  bowel  cannot 
be  brought  to  the  anal  margin,  the  operation  has  to  be  terminated  by 
a  perineal  anus.  This  can  never  be  foretold  previously  to  operation. 
An  inguinal  is  better  than  a  perineal  anus,  (iii)  Little,  if  any,  of 
the  mesentery  of  the  pelvic  colon  is  removed  ;  hence  the  glandular 
lymphatic  drain  is  very  imperfectly  eradicated. 

Although  some  surgeons  claim  encouraging  ultimate  results  from 
these  perineal  operations,  the  majority  agree  that  recurrence  is  very 
frequent.    Indeed,  one  surgeon  reports  recurrence  within  periods  from 


RKCTAL   CAKC1NOMA:   TREATMENT  723 

m\  moni  lis  to  t  hive  years  in  no  fewer  t  linn  54  out  of  a  total  oi  57  ■ 
The  recurrences  are  found  t<>  be  in  the  lymphatic  glands  of  the  pelvic 
mesocolon,  in  the  pelvic  peritoneum,  and  in  the  bowel  ends.  Thai  is, 
recurrence  takes  place  above  the  level  of  previous  operative  inter- 
ference, and  in  tissues  which  might  have  been  removed  by  a  more 
extended  operation. 

2.  The  combined  abdomino-perineal  operation.  —  This 
procedure  attempts  to  remove  more  thoroughly  the  tissues  invaded 
!>v  the  upward  spread  of  the  cancer.  There  are  two  methods  of 
executing  it  : 

(a)  The  greater  part  of  the  pelvic  colon  and  its  mesentery  are 
removed  and  a  permanent  iliac  colostomy  established. 

(b)  Only  the  lower  part  of  the  pelvic  colon  is  removed  and  a  corre- 
sponding length  of  mesentery,  the  cut  end  of  the  pelvic  colon  being 
brought  to  the  anus  and  stitched  to  the  skin  there,  or  if  circumstances 
permit  the  lower  rectum  is  left  and  anastomosed  to  the  pelvic  colon. 

In  both  cases  the  removal  is  commenced  through  the  abdomen. 

In  (a)  merely  a  sufficient  loop  of  the  pelvic  colon  is  left  to  permit 
establishment  of  a  permanent  iliac  colostomy.  The  pelvic  colon  and 
its  mesentery  are  divided,  the  vessels  ligatured  and  the  peritoneum 
incised  on  either  side  of  the  bowel  to  the  level  of  the  recto-vesical 
or  recto-vaginal  reflexion.  All  the  tissue  is  removed  from  the  front 
of  the  sacrum.  The  peritoneum  is  divided  at  the  base  of  the  bladder 
or  vagina,  and  the  rectum  separated  from  the  parts  in  relation  to  it 
anteriorly  and  laterally.  The  ureters  will  probably  be  seen  and  must 
be  carefully  avoided.  When  the  bowel  has  been  freed  as  far  as  is 
possible,  i.e.  to  the  base  of  the  bladder  anteriorly  and  to  the  levatores 
ani  laterally,  it  is  pushed  to  the  bottom  of  the  pelvis  and  the 
peritoneal  covering  of  the  pelvic  floor  is  repaired  as  far  as  possible. 
In  the  exaggerated  lithotomy  or  the  prone  position  the  coccyx  is 
excised,  and  the  rectum,  and  as  much  as  possible  of  the  surrounding 
tissues,  including  a  considerable  portion  of  the  levatores  ani,  the 
sphincter  muscles,  and  the  tissues  of  the  ischio-rectal  fossa?,  together 
with  the  colon,  are  removed. 

In  (b)  the  object  of  the  operation  is  to  remove  the  disease  exten- 
sively and  to  bring  the  pelvic  colon  to  the  anal  margin.  The  superior 
haemorrhoidal  vessels,  even  when  the  bowel  is  otherwise  freed,  will 
from  their  comparative  shortness  prevent  the  colon  being  brought 
to  the  anus.  Hence  these  vessels  must  be  isolated  from  all  connexions 
and  ligatured  cleanly,  no  surrounding  tissue  being  included  in  the 
ligature.  If  the  artery  be  ligatured  immediately  above  the  origin  of 
the  lowest  sigmoid  branch,  there  is  probably  little  danger  of  gangrene 
of  the  bowel  to  be  brought  to  the  anus,  for  collateral  circulation 
is  established  through  the  arch  formed  by  it  and  the  lowest  sigmoid 


724  RECTUM   AND   ANAL    CANAL 

artery.  The  hemorrhoidal  vessels  having  been  ligatured  and  divided, 
the  peritoneum  is  severed  as  in  (a),  and  the  separation  of  the  rectum 
from  its  connexions  is  also  conducted  in  a  similar  maimer.  The  opera- 
tion is  completed  from  the  perineum  after  removing  the  coccyx,  but 
the  sphincters  are  preserved,  or  by  some  surgeons  the  lower  rectum. 
In  the  former  method  the  bowel  is  drawn  down  and  removed  so  that 
the  portion  within  the  grasp  of  the  sphincters  is  without  tension,  and 
it  is  there  sutured  ;  in  the  latter,  the  pelvic  colon  is  anastomosed  to 
the  rectum.  In  this  operation,  less  bowel  will  generally  be  removed, 
and  hence  less  of  the  mesentery  of  the  pelvic  colon,  than  in  (a). 

Choice  of  methods. — When  weighing  the  respective  values  of 
the  operation  performed  entirely  from  the  perineal  aspect,  and  that 
by  the  combined  abdominoperineal  method,  two  points  have  to  be 
considered,  viz.  the  relative  mortalities  and  the  end-results. 

Mortality. — All  operations  for  rectal  cancer  are  prolonged  and 
severe,  and  accompanied  by  considerable  shock.  The  immediate 
mortality,  therefore,  is  by  no  means  slight.  In  addition,  the  prolonged 
suppuration  in  the  perineal  wound  which  sometimes  occurs  may  lead 
to  a  fatal  issue  in  persons  already  enfeebled  by  a  rectal  cancer  and  its 
complications.  The  mortality  of  the  Kraske  operation  is  probably 
greater  than  that  of  the  one  performed  entirely  through  the  true 
perineum.  Statistics  of  mortality  given  by  different  surgeons  vary 
widely.  The  mortality  must  obviously  be  influenced  by  the  general 
condition  of  the  patient,  and  the  extent  of  operative  removal  necessary. 
There  is  no  doubt,  however,  that  at  the  present  day  the  immediate 
mortality  of  the  combined  method  of  operating  is  greater  than 
that  of  any  operation  performed  from  the  perineal  aspect  only,  and 
this  is  one  great  argument  against  the  routine  performance  of  the 
abdominoperineal  operation. 

End-results. — These,  again,  are  very  various  as  given  by  different 
authorities,  but  the  majority  of  surgeons  agree  that  recurrence  after 
perineal  excision  and  the  Kraske  operation  is  very  frequent.  We  have 
not  yet  sufficient  statistics  to  show  that  the  combined  operation  is 
followed  by  a  more  lasting  freedom  from  recurrence. 

The  combined  method  is  theoretically  superior  to  any  perineal 
operation,  but  its  relatively  higher  mortality  necessitates  careful 
selection  of  the  subjects.  They  should  be  moderately  spare,  not  too 
old,  free  from  arterial  degeneration  or  pulmonary  disease,  and  other- 
wise sound  in  constitution. 

In  favour  of  the  abdominal  approach  it  may  be  urged  :  (1)  That  the 
liver  and  other  viscera  may  be  palpated  for  metastases,  in  the  presence 
of  which  the  patient  may  be  spared  any  mutilating  operation.  (2)  That 
glandular  enlargement  may  be  observed  and  feasibility  of  removal 
decided.    (3)  That  the  pelvic  peritoneum  may  be  seen  and  felt  (and,  of 


RECTAL   CARCINOMA  :  TREATMENT  725 

obtuse,  the  whole  peritoneum,  for  it  Bometimea  happens  thai  secondary 

nodules  may  be  scattered  over  the  peritoneum  without  clinical  evidence 
of  their  presence).  (4)  That  an  inspection  of  the  mesentery  of  the  pelvic 
colon  will  generally  enable  the  operator  to  determine  whether  it  i- 
sufficiently  extensive  to  permit  of  the  colon  being  brought  to  the  anal 
margin  if  it  is  intended  to  adopt  this  method  ;  if  this  seems  to  be 
impossible,  an  iliac  colostomy  may  be  established,  thus  abolishing  any 
possibility  of  having  to  terminate  a  perineal  operation  by  the  formation 
of  a  perineal  anus.  (5)  That  it  is  the  only  way  in  which  the  pelvic  colon 
can  be  sufficiently  freed  and  its  blood  supply  safely  preserved  in  order 
that  it  may  be  brought  to  the  anus  if  this  method  be  thought  desirable, 
for  by  ligating  the  superior  haemorrhoidal  artery  immediately  above 
the  origin  of  the  lowest  sigmoid  artery,  the  arterial  arch  between  the 
two  vessels  is  preserved  and  the  blood  supply  to  the  bowel  is  ensured. 

(6)  That  as  gangrene  of  the  transplanted  bowel  does  not  occur,  as  it 
not  infrequently  does  in  the  perineal  method  of  operating,  convales- 
cence  is    much    shortened    and    stricture   is    less    liable    to    follow. 

(7)  That  a  far  wider  severance  and  removal  of  perirectal  tissues  can 
be  performed  than  by  either  of  the  perineal  methods  of  operating. 

If  it  be  proposed  to  perform  the  combined  operation,  it  has  still  to 
be  determined  which  is  the  better  of  the  two  methods  to  pursue. 
Time  alone  will  decide  whether  the  end-results  of  the  more  extensive 
removal  of  the  tissues  are  a  sufficient  compensation  for  the  loss  of 
the  normal  anus.  Theoretically,  the  former  operation  would  seem 
to  offer  the  best  results,  but  naturally  there  will  be  great  aversion 
on  the  part  of  a  patient  to  have  to  submit  to  any  artificial  anus  when 
the  other  alternative  seems  possible. 

An  iliac  colostomy  is  preferable  to  any  perineal  anus.  In  the 
latter  an  infection  of  the  mucosa  frequently  occurs  from  the  surrounding 
wound.  The  escape  of  the  discharges  from  the  inflamed  mucosa  are 
very  annoying.  An  artificial  anus  in  the  iliac  region  can  be  attended 
to  by  the  patient  himself,  and  a  daily  irrigation  will  render  him  com- 
paratively comfortable. 

Treatment  of  irremovable  cancer.  —  Discovery  of  an 
irremovable  rectal  cancer  does  not  always  demand  immediate  perform- 
ance of  colostomy.  A  few  cases  of  rectal  cancer  will  run  their  course 
without  any  necessity  for  the  operation.  There  is  little  evidence  to 
show  that  the  rate  of  growth  is  delayed  by  diverting  the  passage  of 
faeces  over  it,  but  symptoms  may  be  very  much  relieved.  The  indica- 
tions for  a  palliative  colostomy  are — 

Intestinal  obstruction,  acute  or  chronic. 

Haemorrhage  apparently  caused  by  faeces  passing  over  the  growth. 

Pain  caused  by  the  presence  of  faeces  in  the  bowel. 

The  teasing  diarrhoea. 


726 


RECTUM   AND   ANAL   CANAL 


gJ^ 


Haemorrhage  and  diarrhoea  may  be  relieved  by  curettage  and 
cauterization,  but  the  symptoms  will  almost  surely  recur,  when  the 
process  may  be  repeated. 

Carcinoma  of  the  Anal  Canal 

Anal  cancer  (Fig.  517)  originates  from  the  lining  of  the  anal  canal 
or  the  skin  of  the  anal  margin.  There  is  evidence  to  show  that  in  a 
few  cases  it  has  grown  from  the  edge  of  a  chronic  fissure  or  ulcer. 

Generally  speak- 
ing, the  squamous- 
celled  tumour  is  of 
slower  growth  than 
the  glandular  can- 
cer, and  usually 
cancer  of  the  anal 
canal  conforms  to 
this  rule.  Anal  can- 
cer is,  however,  of 
more  rapid  growth 
than  many  forms  of 
skin  cancer.  The 
disease  spreads  (1) 
by  continuity  of  tis- 
sue to  the  skin  of  the 
perineum  (though  it 
does  not  tend  to 
infiltrate  the  rectal 
wall  to  any  extent), 
(2)  by  the  lymphatic 
system.  The  glands 
invaded  are  those 
in  the  groin — the  oblique  set  of  the  inguinal  glands. 

Symptoms. — Since  the  growth  is  at  the  anal  margin,  pain  is 
present  from  the  outset.  At  first  only  experienced  when  the  bowels 
move,  it  later  becomes  more  or  less  constant.  Some  blood-stained 
discharge  occurs  early,  and  this  is  constant,  and  independent  of  the 
bowel  action.  Pruritus  ani  may  be  severe.  Symptoms  of  intestinal 
obstruction  may  or  may  not  be  present,  depending  upon  the  degree 
of  occlusion  of  the  anal  canal.  As  the  growth  infiltrates  the  sphincters, 
incontinence  of  faeces  results.  On  examination  there  will  be  seen  the 
typical  appearance  of  a  squamous-celled  carcinoma. 

Diagnosis. — The  disease  has  to  be  differentiated  from  a  chronic 
indolent  fissure,  condylomata  and  gummatous  ulceration  at  the  anal 
margin,  and  also  from  tuberculous  infiltration  of  the  anal  canal. 


Fig.  517. 


-Section  of  squamous-celled  cancer 
of  anal  canal. 


PRURITUS   AM  727 

Treatment.  Tins  consists  in  early  and  free  removal.  In  all 
cases,  whether  obviously  enlarged  or  not,  the  ingninal  glands  <>f  both 
groins  must  be  freely  removed.  It  is  impossible,  for  anatomical  reasons, 
to  remove  the  primary  growth  and  lymphatic  drain  in  one  piece.  The 
glandular  operation  is  naturally  performed  first.  The  removal  <»f  the 
primary  growth  is  conducted  in  a  manner  similar  to  that  described 
already  (p.  721)  for  the  removal  of  a  rectal  cancer  through  the  true 
perineum.  The  cut  ends  of  the  bowel  are  sutured  to  the  perineal 
skin.  No  attempt  can  be  made,  of  course,  to  preserve  the  external 
sphincter  muscles. 

PRURITUS    ANI 

An  affection  of  the  perianal  skin,  in  which  the  one  symptom  is  itching. 
There  are  two  distinct  clinical  conditions — (1)  that  due  to  some  obvious 
« >urce  of  irritation.  (2)  that  occurring  independently  of  any  lesion  in  the 
M-ctum  or  the  anal  canal. 

1.  The  irritation  may  be  set  up  by  oxyuridea  or  by  the  discharges  from 
internal  haemorrhoids,  fistula?,  ulcers  within  the  anal  canal,  or  from  tumours, 
simple  or  malignant.  It  may  arise  from  the  unconscious  escape  of  mucus, 
owing  to  weakness  of  the  sphincters,  whether  natural  to  the  patient  or  due 
to  prolapse  or  to  previous  operation.  It  may  also  result  from  lack  of  local 
cleanliness,  or  the  presence  of  redundant  circumanal  folds  which  allow  of 
the  collection  of  secretion  or  faecal  matter.  In  advanced  cases  the  itching 
is  intolerable,  rendering  the  patients  very  depressed  and  at  times  suicidal. 
It  varies  from  day  to  day.  and  from  week  to  week  ;  it  is  worse  at  night-time 
and  when  the  body  is  thoroughly  warmed.  When  the  condition  has  been 
present  for  some  time  the  skin  of  the  perineum  shows  evidences  of  prolonged 
and  forcible  scratching  ;  the  dermatitis  extends  backwards  over  the  coccyx, 
forwards  over  the  scrotum  or  vulva,  and  outwards  over  the  buttocks. 

The  primary  cause  must  be  removed.  After  this,  when  the  condition  is  of 
long  standing,  itching  will  not  be  relieved  at  once,  and  local  tieatment  may 
be  necessary.  No  one  application  will  suit  all  cases.  The  changes  must  be 
rung  between  powders,  ointments,  and  lotions.  If  the  itching  is  acute  a 
soothing  application  is  preferable,  but  if  chronic  a  stimulating  remedy  is  more 
efficacious.  Before  any  application  the  parts  should  be  washed  with  some 
non-irritating  soap,  e.g.  Castile  soap,  or  oatmeal  and  water,  and  carefully 
dried.  The  powders  may  contain  -boric  acid,  starch,  zinc  oxide,  calomel, 
calamine,  bismuth,  etc.  Ointments  may  contain  any  of  these,  or  chloroform, 
morphia,  cocaine,  salicylic  acid,  aconite,  subacetate  of  lead,  balsam  of 
Peru,  belladonna,  ichthyol,  etc.  Many  of  these  substances  may  be  used 
in  lotions. 

2.  This  variety  is  regarded  as  a  nervous  manifestation,  possibly  associated 
with  the  gouty,  the  neurotic,  or  some  other  constitutional  diathesis.  The 
patients  are  often  of  the  nervous  irritable  type,  and  the  pruritus  is  rendered 
worse  after  any  excitement  or  nervous  strain. 

The  skin  involved  is  an  elliptical  area,  supplied  by  the  3rd  and  4th  sacral 
nerves,  immediately  surrounding  the  anus,  and  extending  up  the  anal  canal, 
back  nearly  to  the  coccyx  and  anteriorly  along  the  perineum  ;  it  becomes 
dry,  thin,  and  atrophic. 

The  condition  may  be  relieved  by  one  or  other  of  the  drugs  already  men- 
tioned, but  often  only  temporarily.  Good  results  from  the  employment  of 
radium  are  reported  by  Sir  Malcolm  Morris  and  others.     In  cases  in  which 


728  RECTUM   AND   ANAL   CANAL 

all  other  methods  fail,  operative  treatment  must  be  advised,  if  the  symptoms 
are  severe.  The  object  of  the  operation  is  to  cut  all  the  nerves  going  to  the 
affected  skin. 

A  curved  incision  is  made  on  each  side  of  the  anus,  just  externally  to  the 
affected  part,  and  prolonged  forwards  and  backwards,  leaving  the  diseased 
skin  attached  by  two  pedicles  in  the  mid-line,  anteriorly  and  posteriorly. 
The  flaps  of  skin  are  dissected  from  subjacent  tissues,  and  anteriorly  and 
posteriorly  where  it  remains  attached  it  is  undercut  so  that  it  is  entirely 
severed  from  its  deep  connexions.  Haemorrhage  is  arrested  most  carefully,  as 
the  occurrence  of  a  haematoma  may  endanger  the  vitality  of  the  flaps,  which 
are  replaced  and  retained  by  sutures.  Sensation  returns,  but  not  the  pruritus. 
Occasionally  a  spot  or  two  of  skin  does  again  suffer  from  pruritus,  but  this 
may  be  treated  in  a  similar  way. 

BIBLIOGRAPHY 

Anderson,   "  The    After-Result  of  the   Operative  Treatment  of  Haemorrhoids," 

Brit.  Med.  Journ.,  1909. 
Bastianelli,  "  Principles  of  a  Radical  Treatment  for  Procto-Sigmoiditis,"  Ann.  of 

Surg.,  1909. 
Blake,  "  Excision  of  Carcinoma  of  the  Rectum  by  the  Combined  Method,"  Ann. 

of  Surg.,  1908. 
Bruce,   "  The  Treatment  of   Ulcerative   Proctitis  by  Zinc   Kataphoresis,"    Proc. 

Roy.  Soc.  Med.,  1908. 
Buchanan,  "  Excision  of  the  Rectum  for  Cicatricial  Stricture  by  the  Combined 

Method,  with  Preservation  of  the  Sphincter,"  Surg.,  Gyn.,  and  Obstet.,  1907. 
Cunningham,  "  Procidentia  Recti :  Treatment  by  Excision,"  Ann.  of  Surg.,  1909. 
Discussion  on  the  Operative  Treatment  of  Cancer  of  the  Rectum,  Proc.  Roy.  Soc. 

Med.,  1911. 
Gaudiani,  "  Beitrage  zur  Aetiologie  und  Behandlung  der  entziindlichen  Mastdarm- 

stenosen,"  Deuts.  Zeits.  f.  Chir.,  Bd.  xcvi. 
Handley,  "Surgery  of  the  Lymphatic  System,"  Hunterian  Lectures,  Brit.  Med. 

Journ.,  1910. 
Hartmann,  "  Some  Considerations  upon  High  Amputation  of  the  Rectum,"  Ann. 

of  Surg.,  1909. 
Keith,  "  Malformations  of  the  Hind-End  of  the  Body,"  Brit.  Med.  Journ.,  1908. 
Lusk,  "  Excision  of  the  Rectum  for  Cancer,"  Surg.,  Gyn.,  and  Obstet.,  1908. 
Lusk,  "  A  Technique  of  Resection  of  the  Male  Rectum,"  Surg., Gyn., and  Obstet.,  1909. 
Lusk,  "  Resection  of  the  Male  Rectum  for  Cancer,  by  the  Combined  Method  in 

Two  Stages,"  Ann.  of  Surg.,  1910. 
Mayo,  "  Removal  of  the  Rectum  for  Cancer :  a  Statistical  Report  of  120  Cases," 

Ann.  of  Surg.,  1910. 
Miles,  "  A  Method  of  performing  Abdominoperineal  Excision  for  Carcinoma  of 

the  Rectum  and  of  the  Terminal  Part  of  the  Pelvic  Colon,"  Lancet,  1908. 
Miles,  "The  Radical  Abdominoperineal  Operation  for  Cancer  of  the  Rectum  and 

of  the  Pelvic  Colon,"  Brit.  Med.  Journ.,  1910. 
de  Muls,  "  Haemorrhoids  in  Children,"  Arch,  of  Pediatrics,  1905. 
Ronchet,  "  De  l'Amputation  Abdomino-Perineale  du  Rectum  Cancereux,"    Arch. 

Gen.  de  Chir.,  1908. 
Schumann,  "  Ueber  des  Sarcoma  recti,"  Deuts.  Zeits.  f.  Chir.,  Bd.  cii. 
Sheldon,  "  The  Technique  of  Resection  for  Prolapse  of  the  Rectum,"  Surg.,  Gyn., 

and  Obstet.,   1910. 
Wood-Jones,  "  The  Nature  of  the  Malformations  of  the  Rectum  and  Uro-Cenital 

Passages,"  Brit.  Med.  Journ.,  1904. 
Zesas,  "  Les  Hemorro'ides  chcz  1' Enfant,"  Arch.  Gen.  de  Chir.,  190S. 


THE   LIVER,   GALL-BLADDER,    BILE 
PASSAGES,    AND   PANCREAS 

By  G.  GREY  TURNER,   M.S.Durh.,  F.R.C.S.Eng. 

Anatomy   of  the   liver  and   of    the  biliary   apparatus. 

— The  liver  measures  a  little  more  than  6  in.  in  the  greatest  verti- 
cal direction,  and  a  little  less  than  6  in.  antero-posteriorly.  Its 
.summit  reaches  to  the  upper  border  of  the  right  5th  rib  at  a  point 
1  in.  internal  to  the  mammary  line,  and,  therefore,  is  not  directly 
accessible  without  traversing  the  pleura,  lung,  and  diaphragm.  Some 
part  of  each  of  the  6th,   7th,  8th,  9th,  10th,  and  11th  ribs  lies  over 


cqyr<?<>-  splenic 


■bPLENIC    POUCM 


Round      ugrmemt   of  LiveR 
les4e.r     omentum 

HEPRTIC    q«TERY 

Bile    duct 
Portal    vein 

FORRMEN      OF   WlMSLOW 


YFNR    cavfl 


HEPATIC    VOUCH 


UCNO-RENdL    LlCPMENT 
LEFT  MPNEY 


Wight    KiONEY 


Fig.  518. — Transverse  section  of  the  peritoneal  cavity  at  level  of 
foramen  of  Winslow. 

the  liver,  as  well  as  the  cartilages  from  the  6th  to  the  9th,  while  the 
pleura  extends  to  within  2  in.  of  the  costal  margin. 

The  peritoneal  space  just  below  the  liver — the  hepatic  pouch  (Fig. 
518) — is  important,  for  here  collections  may  form  when  the  gall-bladder 
leaks. 

The  gall-bladder  (Fig.  519)  is  usually  pear-shaped,  and  has  a  capacity 
of  H  oz.  At  its  junction  with  the  cystic  duet  there  is  often  a  lateral  pouching 
called  the  pelvis,  or  Hartmann's  pouch,  which,  when  distended,  may  be 
mistaken  for  the  commencement  of  the  cystic  duct. 

The  cystic  duct  is  about  H  in.  in  length  and  runs  downwards  and  to 
the  left  to  join  the  common  hepatic  duct.    Its  lumen,  normally  only  J  in.  in 

729 


/30 


THE   LIVER 


diameter,  is  further  narrowed   by   spiral  folds — Heister's   valves — so  that, 
unless  dilated,  it  does  not  permit  the  passage  of  a  probe. 

The  cystic  artery  lies  to  the  inner  side  of  the  duct,  and  is  not  in 
direct  contact  with  it.  In  the  angle  between  the  cystic  and  the  hepatic  ducts 
one  or  more  lymphatic  glands  are  constantly  present,  and,  when 
enlarged,  may  closely  simulate  calculi. 


Fig.   oil). — Diagram  of   the   gall-bladder  and   bile-ducts. 

The  black  outlines  represent  the  normal  conditions  ;    red  indicates  a  calculus  impacted  in  the 

■  ystic  duct,   with  consequent  distension  of  the  gall-bladder  and  no  jaundice  ;  and  green,  a 

stone  in  the  lower  end  of  the  common  duct,  with  a  contracted  and  thickened  gall-bladder, 

and  deep  jaundice. 

The  common  hepatic  duct  is  about  \\  in.  in  length,  while  the 
common  bile-duct  is  about  3  in.  long  and  ,,  in.  in  diameter,  and  may 
conveniently  be  divided  into  three  portions. .  The  first  or  supraduodenal 
jwrtion  extends  to  the  upper  border  of  the  duodenum,  in  the  free  edge  of  the 
gastro-hepatic  omentum.    Behind  it  runs  the  portal  vein,  and  to  its  inner  side 


MISPLACEMENTS   AND    INJURIES  731 

the  hepatic  artery.  This  portion  of  tin-  dint  is  often  in  relation  with  0116  0T 
two  lymphatic  glands,  and  small  veins  or  an  arterial  twig  ma\  cross  it  .and 
be  the  Bource  of  serious  haemorrhage  if  wounded.  The  secoml  m-  rrtroihiotlrmd 
portion  is  1  in.  to  1J-  in.  long,  and  in  two  cases  out  of  three  is  more  or  less 
surrounded  by  panoreas.  The  third  or  transduodenal  portion  passes  obliquely 
through  the  duodenal  wall  and  ends  in  the  ampulla  of  Valer,  which  opens 
into  the  bowel  on  a  papilla.  The  common  duct  gradually  diminishes  in 
diameter  from  8  mm.  at  the  beginning  to  i2\">  mm.  at  its  orifice. 

THE  LIVER 

MALFORMATIONS   AND    MISPLACEMENTS 

As  a  result  of  constriction  by  corsets  and  belts,  the  liver  may  be  pushed 
up,  or  may  be  flattened  antero-posteriorly  with  downward  elongation  of  the 
whole  of  the  right  lobe,  or  of  its  lower  border. 

Sometimes  a  definite,  very  mobile,  tongue-like  lobe  arises  by  a  broad 
attachment  or  a  thin  pedicle  from  the  lower  border,  without  elongation  of  the 
whole  lobe.  Such  a  process  ("floating  lobe"  or  "  RiedeVs  lobe'''')  is  often 
associated  with  gall-stones.  It  is  distinguishable  from  an  enlarged  kidney 
by  the  facts  that  it  can  be  pushed  beyond  the  middle  line,  and  that  the 
kidney  can  be  felt  separately. 

Hepatoptosis,    or   Movable   Liver 

Dislocation  of  the  normal  liver  is  only  commonly  met  with  in  association 
with  general  visceroptosis  (Glenard's  disease).  The  liver  is  displaced  down- 
wards and  rotated  so  that  the  upper  surface  looks  forwards,  and  the  heavier 
right  lobe  is  advanced  inwards  as  well  as  downwards.  It  may  be  loose  and 
replaceable,  or  may  be  fixed  in  its  abnormal  position.  Total  hepatoptosis, 
a  rare  condition,  is  commonest  in  women  between  40  and  60. 

Etiology. — Ptosis  may  be  due  to  congenital  weakness  of  the  hepatic 
supports,  and  has  been  met  with  in  children.  The  exciting  cause  may  be 
trauma,  but  is  usually  the  general  weakening  associated  with  rapid  child- 
bearing  or  with  neurasthenia. 

Treatment.— When  the  visceroptosis  is  general,  most  benefit  is  likely 
to  accrue  from  abdominal  massage  and  exercises  (Swedish),  combined  with  a 
well-fitting  abdominal  belt  or  corset.  For  hepatic  displacement  alone,  attempts 
have  been  made  to  support  the  organ  by  forming  adhesions  between  the 
liver  and  the  parietes,  by  shortening  the  suspensory  ligament,  or  by  stitching 
the  edge  of  the  liver  to  the  abdominal  wall. 

INJURIES 

The  liver  is  more  often  injured  than  any  other  solid  abdominal 
organ.  Usually  the  violence  is  direct  and  considerable.  The  injury 
may  be  entirely  subcutaneous,  or  associated  with  an  open  wound. 

Morbid  anatomy. — The  right  lobe  is  involved  six  times  as 
often  as  the  left,  and  the  convexity  twice  as  often  as  the  concavity. 
The  actual  injury  to  the  liver  may  take  the  form  of  a  contusion,  a 
subcapsular  rupture,  or  a  laceration.  In  the  subcapsular  variety  the 
liver  may  be  very  extensively  torn,  leaving  a  gap  an  inch  or  more 
wide  beneath  its  capsule  (Fig.  520).     Whatever   the  type,  the  most 


732 


THE    LIVER 


serious  feature  is  haemorrhage,  either  into  the  peritoneal  cavity  or 
into  the  liver  or  ducts. 

Injuries  to  the  diaphragm,  lung,  stomach  or  bowel,  kidney  or  spleen 
are  often  serious  complications. 

Clinical  features. — With  the  slighter  injuries  there  may  be 
only  mild  shock  with  rigidity  and  tenderness  over  the  liver  and  limita- 
tion of  respiratory  movement.  Later,  there  may  be  some  jaundice 
and  glycosuria  ;  and  later  still,  perhaps,  evidence  of  infection.  As  a 
rule,  there  is  severe  pain  with  great  tenderness  over  the  liver,  and 
extreme  general  rigidity,  the  chest  being  held  almost  still.  Marked 
pallor  suggests  grave  internal  haemorrhage,  and  it  may  be  possible 
to  detect  free  fluid  in  the  abdominal  cavity.     In  cases  that  survive, 

f 

i 


Fig.  520. — Old  subcapsular  laceration  of  the  liver. 

distension  soon  ensues,  and  jaundice  commonly  occurs  some  days 
after  the  injury. 

Diagnosis. — The  cases  may  be  arranged  in  three  groups : 
(a)  Those  with  signs  of  overwhelming  internal  haemorrhage,  but  with 
nothing  to  indicate  its  source  ;  (&)  those  with  evidence  of  severe 
haemorrhage,  with  injury  to  the  parietes,  fracture  of  ribs,  or  localized 
pain  and  tenderness  over  the  liver  region  ;  (c)  those  in  which  the  site 
of  the  injury  suggests  a  possible  rupture  of  the  liver,  but  in  which 
there  are  no  signs  of  haemorrhage,  but  only  localized  tenderness  and 
rigidity,  with  subsequent  enlargement  of  the  liver  and  some  slight 
jaundice. 

Prognosis. — Injuries  sufficiently  serious  to  demand  surgical 
interference  are  attended  with  a  mortality  of  60  or  70  per  cent.  The 
lesser  degrees  of  contusion  or  laceration  may  recover  spontaneously, 
but  the  possibility  of  late  death  from  secondary  haemorrhage,  infection, 
or  pulmonary  embolism  must  be  remembered. 

Treatment. — In  open  wounds  it    is    always  wise   to    operate. 


HEPATIC   ABSCESS  733 

In  subcutaneous  injuries,  evidence  of  severe  hemorrhage,  <>r  in  the 
milder  cases  an  increasing  pulse-rate  or  persistence  "l  tenderness  and 
fluidity,  indicates  interference. 

In  operating  if  must  be  borne  is  mind  thai  the  haemorrhage  is 
partly  controlled  by  the  rigidity  <d  the  abdominal  muscles,  and  thai 
as  soon  as  this  is  relaxed  the  bleeding  may  become  furious. 

The  best  incision  is  ;t  median  one  from  the  xiphisternum  to  the 
umbilicus.  Exposure  of  a  laceration  far  back  on  the  convexity  may 
require  a  cross-cut  to  the  right  or  division  of  the  suspensory  and 
right  lateral  ligament.  Haemorrhage  may  be  temporarily  checked  by 
grasping  the  portal  vein  and  hepatic  artery  between  the  fingers  in 
the  foramen  of  Winslow  and  the  thumb  in  front.  Lacerations  should 
be  sutured,  if  possible,  but  if  the  site  of  injury  cannot  be  easily  ex- 
posed, reliance  should  be  placed  on  immediate  packing  with  gauze. 
Sometimes  a  combination  of  the  two  methods  is  useful. 

Often  in  stab  wounds  the  diagnosis  can  only  be  confirmed  by 
laparotomy,  which  may  have  to  be  combined  with  a  transpleural 
incision  along  the  track  of  the  knife. 

In  the  after-treatment  of  liver  injuries,  secondary  hsemorrhage, 
abscess — intrahepatic  or  perihepatic — and  biliary  fistula  must  be 
watched  for. 

SURGICAL    INFECTIONS 

Liver  Abscess 

Multiple  liver  abscesses  may  result  from  infection  conveyed  by 
(a)  the  hepatic  artery,  (b)  the  portal  vein,  (c)  the  bile-ducts,  or  (d)  direct 
continuity. 

Single  liver  abscesses. — The  most  typical  is  the  tropical  dysenteric 
abscess.  This  generally  results  from  infection  by  the  Amoeba  dysenteric, 
only  occasionally  complicating  the  bacterial  form  of  tbe  disease.  The 
white  races,  especially  males  over  40,  furnish  90  per  cent,  of  the  cases. 
The  abscess  may  occur  at  any  stage  of  the  disease,  or  long  after  all 
dysenteric  symptoms  have  disappeared.  Alcohol,  free  living,  and 
exposure  are  all  exciting  causes. 

Morbid  anatomy. — In  about  70  per  cent,  of  cases  the  abscess 
is  confined  to  the  right  lobe,  the  posterior  and  upper  part  being  the 
favourite  site.  Though  usually  spoken  of  as  "  solitary."  in  about 
40  per  cent,  of  cases  there  is  more  than  one  abscess.  (Fig.  521.)  The 
contents  of  the  abscess  cavity  are  usually  chocolate-coloured,  very 
viscid,  and  not  offensive.  The  abscess  may  extend  into  the  sur- 
rounding healthy  liver,  may  burst  into  the  peritoneum,  the  lung,  or 
more  rarely  externally,  or  may  shrivel  up  and  its  contents  become 
inspissated. 

Clinical  features. — The  symptoms  are  characteristically  vari- 


HEPATIC   ABSCESS  735 

able.  There  may  be  dull  pain  over  the  liver  region,  or  sometimes 
over  the  acromion,  a  tendency  to  stoop  t<>  the  right,  and  perhaps 
coughing  on  deep  inspiration.  The  temperature  may  be  continuously 
elevated  or  regularly  variable,  simulating  malaria  ;  or  it  may  \><-  ver] 
little  elevated,  and  in  some  chronic  'uses  may  be  normal  or  subnormal. 
Sweating  La  usually  profuse,  the  skin  yellowish  and  [<earthy,"  and 
wasting  marked. 

Physical  signs. — The  liver  is  enlarged,  usually  upwards,  pro- 
ducing dullness  almost  as  high  as  the  Boapular  angle.  The  whole 
hepatic  region  is  commonly  bulged  and,  later,  tender  on  deep  pressure. 

Diagnosis. — From  malaria  diagnosis  is  made  by  blood  examina- 
tion and  by  the  effect  of  quinine.  The  upward  enlargement  of  the 
liver  is  unlike  that  seen  in  suppurating  gall-bladder  and  in  cancer, 
but  it  may  be  very  difficult  to  distinguish  the  condition  from  sup- 
purating hydatid,  gumma,  or  subdiaphragmatic  abscess.  The  fluor- 
escent screen  may  give  valuable  help,  as  also  may  an  examination  of 
the  fasces  for  amoeba?.  The  diagnosis  is  rendered  certain  by  the  use 
of  the  exploring  needle.  It  is  necessary  to  emphasize  the  ease  with 
which  even  a  large  abscess  ma}*  be  missed  unless  a  thorough  explor- 
ation of  the  liver  be  made.  A  constant  vacuum  should  be  kept  in 
the  syringe  attached  to  the  needle,  which  may  with  safety  be  3|  in. 
long.  The  finding  of  the  abscess  should  be  immediately  followed 
by  operation,  the  needle  being  left  in  situ  as  a  guide.  Amoeba? 
may  be  found  in  the  fluid,  but  prolonged  search  is  often  necessary, 
though  they  are  usually  numerous  iu  the  discharge  from  the  abscess 
on  the  days  following  the  operation. 

Prognosis. — Without  operation  the  prognosis  is  very  bad, 
and  even  surgical  treatment  has  a  mortality  of  about  20  per  cent. 

Treatment. — In  the  few  eases  in  which  the  abscess  is  actually 
invading  the  skin  a  simple  incision,  followed  by  drainage  through 
a  very  large  tube,  will  effect  cure,  ilany  successful  results  have 
been  reported  from  cannula  drainage  carried  out  immediately  after 
the  presence  and  site  of  the  abscess  have  been  determined  by  explor- 
atory puncture,  but  for  surgeons  who  have  no  special  experience  of 
this  class  of  cases  the  open  operation  is  undoubtedly  the  best. 

An  abscess  in  the  hepatic  dome  is  best  approached  by  excision  of 
part  of  the  9th  or  10th  rib,  just  behind  the  mid-axillary  line.  It  may 
be  necessary  to  approximate  the  costal  to  the  diaphragmatic  pleura, 
either  by  stitching  or  by  packing,  and  to  incise  the  diaphragm.  In 
very  many  cases  the  pleura  and  peritoneum  along  the  operative  track 
are  found  to  be  already  adherent. 

When  the  principal  enlargement  is  downwards  the  abdomen  should 
be  opened  by  a  vertical  incision  over  the  prominent  part  through 
the  right    rectus    muscle.     If    the    adhesions    are   not    sufficient,   the 


736  THE    LIVER 

peritoneum  should  be  protected  by  gauze  packing.  The  abscess  is 
then  opened  by  forceps,  and  the  finger  introduced  and  any  secondary 
abscesses  opened.  Drainage  is  secured  by  a  large  rubber  tube,  1  in. 
in  diameter,  wrapped  round  with  gauze  to  prevent  pus  oozing  up  by 
its  sides  before  the  liver  adheres  to  the  parietes.  During  the  first  two 
days  the  pus  should  be  sterile,  and  after  that  should  only  contain 
amoebae.  Every  care  must  be  taken  to  avoid  secondary  infection  if 
the  abscess  is  to  close  rapidly.  As  a  rule  the  eavity  rapidly  contracts, 
but  the  hepatic  enlargement  may  only  slowly  decrease.  It  is  often 
necessary  to  aid  drainage  of  large  cavities  by  initiating  a  siphon 
action  through  the  tube.  Sometimes  there  may  be  a  considerable 
discharge  of  bile,  which  only  ceases  gradually. 

INFECTIVE    GRANTJLOMATA 

Tuberculosis  of  the  liver  is  rare.  It  may  take  the  form  of 
solitary  masses,  and  localized  abscesses  have  been  operated  upon 
successfully.  The  liver  may  be  enlarged,  but  usually  there  are  no 
distinctive  diagnostic  features. 

Syphilis 

Only  the  tertiary  manifestations  are  of  surgical  interest. 

Gummata,  either  single  or  multiple,  may  occur,  often  as  late  as 
five  to  twenty  years  after  infection.  They  form  yellowish  masses, 
accompanied  by  perihepatitis,  and  sometimes  by  diffuse  sclerosis  and 
lardaceous  disease.  The  dome  of  the  right  lobe  is  most  commonly 
affected,  and  the  diaphragm  often  invaded.  Another  common  site  is 
near  the  portal  fissure.  They  may  become  absorbed,  leaving  scars 
which  by  their  contraction  tend  to  cause  syphilitic  cicatrization  or 
even  lobulation  of  the  liver,  or  they  may  break  down,  become  infected, 
and  simulate  abscesses.  Jaundice  is  rare,  but  ascites  may  be  present 
if  the  gumma  obstructs  the  portal  vein. 

Treatment. — Exploration  may  be  advised  in  cases  that  have 
resisted  medical  treatment.  If  the  diagnosis  is  confirmed  the  abdomen 
may  be  closed  and  remedies  persevered  with,  but  when  there  is  doubt 
the  mass  may  be  excised  or  opened  and  some  tissue  scooped  out  for 
examination.  This  interference  may  hasten  the  effect  of  the  appro- 
priate therapeutic  measures,  described  in  Vol.  I. 

CIRRHOSIS 

For  the  treatment  of  the  ascites  an  operation,  now  generally  known 
as  omentopexy,  was  devised  independently  by  Talma  of  Utrecht,  and 
Drummond  and  Morison  of  Newcastle-upon-Tyne,  and  first  success- 
fully practised  by  Morison  in  1895.  This  operation  aims  at  establishing 
an  efficient  collateral  venous  circulation  between  the  abdominal  wall 
and  the  omentum  and  viscera,  thus  helping  to  carry  off  the  portal  blood. 


OMENTOPEXY 


737 


That  this  does  actually  occur  is  proved  by  the  great    development  of 
the  subcutaneous  veins  sonic  time  after  the  operation.    (Fig.  522.) 

The  operation  can  only  be  recommended  for  ascites  depending  on 
alcoholic  cirrhosis  and  due  to  portal  obstruction,  and  not  merely  the 
result  of  toxaemia.  The  patients  selected  should  have  withstood 
several    tappings,    should    be    free    from  * 

pulmonary,  cardiac,  or  renal  disease,  and 
should  become  absolute  teetotalers  after 
recovery. 

A  supra-umbilical  incision  is  made  to 
expose  the  liver  and  spleen  and  confirm 
the  diagnosis.  Then  through  a  small 
suprapubic  opening  a  Keith's  tube  is  in- 
troduced into  Douglas's  pouch,  and  the 
abdomen  emptied  of  fluid.  The  surfaces 
of  the  liver  and  spleen  are  scrubbed  with 
gauze  to  set  up  some  peritoneal  reaction, 
and  the  omentum  is  fixed  at  two  or  three 
points  to  the  parietes,  especially  to  the 
peritoneal  edges  of  the  wound.  After- 
wards the  parietes  are  kept  in  contact 
with  the  liver  and  spleen  by  carefully 
strapping  the  abdomen  from  above  down- 
wards. Continuous  drainage  is  secured 
by  Keith's  tube.  Reaccumulation  of  fluid 
may  demand  one  or  more  tappings.  Some 
operators  dispense  with  drainage  and  de- 
pend on  subsequent  tapping. 

Results. — In  properly  selected  cases 
the  mortality  is  very  low  and  the  after- 
results  are  uniformly  good,  patients  re- 
maining alive  well  for  2,  3,  5,  6,  and  over 
11  years.  (See  Fig.  522.)  The  operation 
has  been  used  for  ascites  due  to  a  great 
variety  of  causes,  but  usually  with  un- 
satisfactory results. 

Drainage  into  the  subcutaneous  tissue 
has  been  suggested   by  Essex  Wynter,  and 
Handley. 

SIMPLE    TUMOURS 

Angiomas  of  the  liver  have  several  times  been  successfully 
removed.  Though  usually  quite  small,  this  species  of  tumour  may 
attain  the  size  of  a  child's  head.     As  operative  interference  may  be 


Fig.  522. — Photograph  of  a 
patient  alive  and  well  1 1 
years  after  omentopexy 
for  alcoholic  cir- 
rhosis. 

The  great  development  of  the  epi- 
gastric veins  is  well  shown  on  the 
right  side.  That  a  similar  condition 
did  not  arise  on  the  left  side  was 
probably  due  to  the  fact  that  the 
patient  always  wore  an  inguinal  iruss. 

(Photograph  kindly  lent  by  Pro- 
fessor Rutherford  M orison.) 


carried  out  by  Sampson 


738  THE    LIVER 

very  dangerous,  and  as  there  is  no  special  tendency  to  become  malig- 
na nt,  these  tumours  are  best  left  alone  unless  there  is  some  distinct 
indication  for  removal. 

MALIGNANT    TUMOURS 

Of  the  malignant  tumours,  the  only  important  variety  from  an 
operative  point  of  view  is  that  which  arises  as  an  extension  from 
malignant  disease  of  the  gall-bladder  (see  p.  760). 

Primary  carcinoma  and  sarcoma  of  the  liver,  though 
rare,  are  important,  because  they  may  occur  in  the  form  of  massive 
growth  which  may  degenerate  and  simulate  a  cyst,  an  abscess,  or  a 
gumma.  The  right  lobe  is  usually  the  one  affected,  the  growth  form- 
ing a  single  large  tumour.     Sarcoma  is  even  rarer  than  carcinoma. 

Secondary  carcinoma  and  sarcoma  are  more  common, 
and  the  growths  are  generally  multiple  and  of  various  sizes. 

Treatment. — When  the  diagnosis  of  secondary  malignant  disease 
is  established,  operative  interference  is  out  of  the  question,  but  explo- 
ration is  certainly  justified  with  a  doubtful  localized  tumour,  for  many 
inflammatory  conditions  are  indistinguishable  from  new  growth.  If. 
as  is  usual,  radical  operation  is  not  feasible,  the  patient  should  be 
given  the  chance  that  a  course  of  iodide  and  mercury  may  offer. 

CYSTS 

Simple  single  cysts  are  rarely  found.  Though  usually  small,  they 
may  attain  the  size  of  a  child's  head.  They  are,  as  a  rule,  situated 
near  the  free  margin  of  the  liver,  and  have  been  found  in  connexion 
with  the  round  ligament. 

Cystadenomas  and  multiple  cystic  disease  also  rarely  occur. 

Hydatids 

These  cysts  occur  in  the  liver  more  frequently  than  in  all  other 
situations  put  together  (63'4  per  cent.).  The  disease  manifests  itself 
between  the  ages  of  20  and  40,  but,  though  uncommon,  cases  do  occur 
in  children,  usually  from  8  to  10  years  of  age. 

Pathology;  morbid  anatomy. — The  tumour  is  usually 
situated  in  the  right  lobe,  either  deeply  embedded  or  pointing  towards 
the  upper  surface.  The  cyst  may  be  single  ;  there  may  be  two  of 
about  the  same  size  ;  or  numbers  of  small  cysts  may  be  present  (the 
multilocular  variety). 

The  true  cyst  is  composed  of  two  layers,  an  outer,  whitish,  firm 
cuticle,  and  an  inner  cellular  layer  from  which  the  scolices  develop. 
These  are  surrounded  by  a  fibrous  capsule  formed  by  an  alteration  of 
the  adjoining  parts.  The  scolices  possess  suckers  and  hooklets,  and, 
though  at  first  attached  to  the  capsule,  later  float  free  in  the  cyst 


HYDATID  CYSTS  739 

fluid.  The  fluid  is  clear,  often  opalescent,  of  specific  gravity  1002  to 
1010,  and,  when  the  cyst  shows  active  growth,  contains  no  albumin. 
Hooldets  may  be  found  in  the  fluid,  but  arc  not  numerous. 

Secondary  changes. — Hydatids  may  die,  the  cysts  usually 
BhiiveUing  up  and  the  contents  becoming  less  fluid  and  more  gelatinous, 
and,  later,  may  become  converted  into  a  cheesy  mass,  Bometimes  with 
calcareous  deposits.  Rupture  may  follow  Blight  trauma* oi  gradual 
erosion.  Suppuration  is  common  and  may  be  determined  by  injury. 
The  infection  may  come  from  the  bile  or  some  adjacent  hollow  viscus, 
or  may  be  haemic  as  in  typhoid  fever. 

Clinical  features. — Hydatid  cysts  usually  obtrude  them- 
selves  on  account  of  their  size,  but  they  may  be  very  large  without 
giving  rise  to  injurious  pressure  on  neighbouring  organs.  The  patient 
may  complain  of  dragging  or  a  feeling  of  weight,  or  of  attacks  of  pain 
depending  on  peritonitis  or  suppuration. 

Physical  signs. — As  a  rule  the  liver  is  enlarged  upwards  and 
may  compress  the  lung,  and  also  cause  bulging  of  the  costal  arch. 
When  the  cyst  can  be  felt  below  the  costal  margin  it  is  dull  and  usually 
very  tense  and  elastic,  so  much  so  that  it  may  resemble  a  solid  tumour  ; 
it  rarely  presents  the  so-called  hydatid  thrill.  Marked  tenderness, 
jaundice,  and  ascites  when  present  are  usually  due  to  inflammatory 
changes,  or  to  pressure  on  bile-ducts,  portal  vein,  or  inferior  vena 
cava.     Jaundice  is  rare. 

Diagnosis. — Malignant  disease  and  cirrhosis,  syphilis,  suppura- 
tion and  hepatoptosis  may  all  be  mistaken  for  hydatids,  and  even  on 
operation  multilocular  hydatids  may  be  difficult  to  diagnose  from 
cancer.  "When  the  hydatid  enlarges  the  liver  upwards,  pleural  effusion 
or  hydatid  disease  in  the  lung  may  be  simulated.  In  these  circum- 
stances skiagraphy  may  help,  the  fluorescent  screen  clearly  showing 
the  diaphragm  and  its  movements.  Exploratory  puncture  should  not 
be  done  when  the  presence  of  hydatids  is  suspected. 

Prognosis. — Although  natural  death  of  the  parasite  may  occur 
at  any  time,  the  cyst  may  burst  and  disseminate,  or  become  infected. 
Perforation  into  the  peritoneum  or  pleura  may  occur  with  fatal  results  ; 
but  rupture  into  the  stomach,  duodenum,  or  bile  passages  is  less 
rapidly  disastrous  and  may  even  result  in  cure. 

Treatment. — The  essential  treatment  is  to  remove  the  mother 
eyst  and  to  deal  with  the  adventitious  capsule  as  best  possible.  Cysts 
that  project  downwards  are  most  safely  reached  through  an  abdominal 
incision,  while  for  those  that  occupy  the  dome  of  the  liver,  and  that 
cannot  be  satisfactorily  reached  from  the  abdomen,  the  thoracic  route 
must  be  chosen,  an  incision  being  made  in  the  8th  or  9th  interspace. 
It  is  necessary  to  protect  the  surrounding  parts  from  contamination 
by  the  fluid,  for  fear  of  secondary  implantation.     This  may  be  done 


740  GALL-BLADDER   AND   BILE-DUCTS 

by  gauze  packing,  or  by  stitching  the  sac  to  the  abdominal  wound 
before  opening  it.  Some  surgeons  prefer  to  divide  the  operation  of 
evacuation  into  two  stages,  leaving  the  opening  of  the  sac  to  a  second 
operation  ten  days  later. 

Whenever  possible,  complete  excision  is  the  ideal  operation.  As, 
however,  the  adventitious  capsule  is  intimately  associated  with  the 
surrounding  parts,  this  can  seldom  be  carried  out ;  but  enucleation  of 
the  true  cyst  may  be  combined  with  partial  excision  of  the  capsule. 
The  large  area  left  after  excision  or  enucleation  may  be  completely 
or  partially  closed  by  tier  sutures,  any  part  not  so  closed  being 
treated  by  gauze  packing.     In  any  case,  drainage  must  be  provided. 

If  excision  is  not  expedient,  the  cyst  should  be  opened  and  emptied, 
and  every  part  of  the  lining  membrane  removed  by  forceps  or  by 
gauze  scrubbing.  The  remaining  cavity  must  be  packed  if  there  is 
much  haemorrhage,  and  in  all  cases  freely  drained. 

Very  large  tumours,  of  which  the  whole  interior  cannot  be  reached; 
should  be  marsupialized  by  stitching  the  edges  to  the  peritoneum  or 
fascia  of  the  parietal  wound.  The  interior  may  then  be  packed  and 
drained. 

GALL-BLADDER   AND  BILE-DUCTS 

MALFORMATIONS 
Congenital  Obliteration  of  the  Bile-Ducts 

This  condition  is  probably  due  to  antenatal  descending  cholangitis. 
Clinically,  there  is  jaundice,  either  at  birth  or  very  soon  afterwards; 
this  rapidly  increases  and  becomes  associated  with  cholsemia  and 
tendency  to  haemorrhage,  life  seldom  being  prolonged  beyond  six 
months. 

Treatment. — In  cases  that  have  survived  infancy  an  opera- 
tion may  be  undertaken.  If  the  gall-bladder  is  not  distended  with 
bile,  cholecyst enterostomy  will  be  useless,  and  an  attempt  will  have 
to  be  made  to  unite  a  dilated  duct  or  a  free  surface  of  the  liver  to  the 
.small  intestine. 

Cystic  Dilatation  of  the  Common  Bile-Duct 

There  are  two  classes  of  cases  :  (a)  those  with  a  free  opening  into 
the  duodenum  ;  (6)  those  with  definite  obstruction  in  the  common 
duct.  The  condition  is  most  frequent  in  children,  but  may  first  show 
itself  about  middle  life.  Clinically,  there  is  a  large  cyst  below  the 
liver,  associated  with  jaundice.  The  onset  is  gradual  and  the  whole 
condition  painless. 

Treatment  must  be  operative,  usually  by  anastomosing  the 
cyst  and  some  part  of  the  intestine,  preferably  the  duodenum. 


RUPTURED   GALL-BLADDER  7V 

INJURIES 

The   gall-bladder   may    be    raptured   Bmbcutaneoualy   or  wounded 

by  a  -tilt  <>r  a  bullet.     A  large  bile-duel  maybe  damaged,  and  there 

may  be  associated    injuries  to   the  liver  or  other  viscera,  or  to  some 
vessel  such  as  the  portal  vein. 
Morbid  anatomy. — The  rent  in  the  gall-bladder  is   usually   .it 

the  fundus,  ami  may  be  a  mere  puncture  or  a  tear  an  inch  or  more 
in  length.  The  ducts  may  be  completely  torn  across,  bu1  more  usually 
only  part  of  the  circumference  is  involved,  so  that  healing  occurs, 
though  stricture  may  follow. 

Clinical  features. — Either  accident  may  be  early  fatal  from 
ociated  injury,  and.  in  any  case,  will  be  attended  with  shock. 
When  the  shock  passes  off,  the  patient  may  appear  to  recover  com- 
pletely,  or  the  abdomen  may  become  distended,  painful,  tender,  rigid, 
and  dull  in  the  right  side,  especially  about  the  iliac  region.  Jaundice 
is  almost  invariable,  and  is  of  diagnostic  importance,  for  it  is  present 
in  65  per  cent,  of  injuries  to  the  bile  passages,  and  only  in  4'75  per 
cent,  of  injuries  to  the  liver.  After  a  time  the  general  abdominal 
distension  diminishes,  but  is  followed  either  at  once  or  in  two  or 
three  weeks  by  the  development  of  a  localized  collection  of  fluid  in 
the  right   side. 

Treatment. — If  an  injury  to  the  bile  passages  is  diagnosed 
early,  an  operation  should  be  carried  out.  A  rent  in  the  fundus  of  the 
gall-bladder  may  be  closed  by  suture  or  used  for  purposes  of  drainage, 
or  the  viscus  removed  altogether.  If  one  of  the  larger  ducts  be  injured 
the  treatment  will  depend  on  the  size  of  the  tear.  A  small  hole  may 
be  treated  by  stitching  a  tube  to  the  margin  of  the  rent,  thus  pro- 
viding for  external  drainage,  but  almost  complete  division  demands 
an  attempt  at  suture,  combined  with  external  drainage. 

In  complete  rupture  of  the  common  duct  it  may  be  possible  to 
reunite  the  ends  or  to  implant  the  proximal  one  into  the  duodenum. 
but  it  will  usually  be  safer  and  easier  to  ligature  both  and  to  perform 
cholecyst  enterostomy  (Terrier). 

In  cases  not  seen  until  a  localized  collection  has  formed,  it  is  best 
merely  to  establish  external  drainage  without  attempting  to  find  the 
hole  in  the  duct. 

INFECTIVE    GRANULOMATA 

Tuberculosis,  whether  of  the  gall-bladder  or  of  the  ducts, 
though  found  after  death  in  a  fair  proportion  of  cases  of  intestinal 
tuberculosis,  is  undoubtedly  very  rare  as  a  clinical  entity.  The  gall- 
bladder has  been  opened  for  suspected  calculi,  but  found  to  contain 
only  tuberculous  granulation  tissue. 

Diagnosis  is  practically  impossible,  though,  singularly,  jaundice 


742  GALL-BLADDER   AND   BILE-DUCTS 

has  always  been  absent.  The  treatment  consists  either  in  excision 
of  the  gall-bladder,  or  in  thorough  curettage  with  use  of  pure  carbolic 
acid,  etc. 

Calcareous  tuberculous  glanda  along  the  cystic  or  common  ducts 
may  simulate  gall-stones. 

Syphilis. — Sometimes  gummata  or  syphilitic  cicatrices  have 
caused  obstruction  of  the  common  duct,  and  given  rise  to  symptoms 
of  gall-stones,  while  a  gumma  in  the  margin  of  the  liver  may  suggest 
a  similar  diagnosis.  Cases  with  a  strong  syphilitic  history  should  be 
given  a  course  of  mercury  and  iodide  before  operation  is  contemplated. 

INFECTIONS 

Cholecystitis 

Cholecystitis  is  much  commoner  than  cholangitis,  owing  to  the 
readier  drainage  of  the  ducts  into  the  intestine. 

Cholecystitis,  though  usually  associated  with  gall-stones,  may 
occur  independently,  and  there  is  evidence  to  show  that  such  infections 
may  exist  for  quite  a  time  before  the  gall-stones  appear. 

This  is  borne  out  by  a  series  of  the  Mayos'  cases  of  cholecystectomy. 
In  365  cases,  all  inflammatory,  gall-stones  were  found  in  only  69  per  cent, 
of  the  specimens  in  an  acute  catarrhal  condition,  in  76  per  cent,  of  the  chronic 
catarrhs,  and  in  93  per  cent,  of  the  advanced  chronic  cases. 

Pathology  of  non-calculous  cholecystitis. — The  causa- 
tive organism  may  reach  the  gall-bladder  either  directly  from  the 
bowel  and  ducts,  or  through  the  blood  stream.  The  commonest 
infections  are  probably  by  B.  typhosus,  Bacillus  cob,  B.  influenza?, 
and  the  pneumococcus,  in  that  order. 

The  different  varieties  of  cholecystitis,  apart  from  the 
special  type  of  causative  organism,  are  really  only  different  stages 
of  the  ordinary  processes  of  inflammation. 

Clinical  features. — The  milder  cases  merely  present  indis- 
tinctive dyspeptic  symptoms.  In  the  more  severe  varieties  there  may 
be  continuous  or  paroxysmal  local  pain  and  tenderness,  with  nausea 
and  vomiting,  catching  of  the  breath,  a  very  slight  tinge  of  jaundice, 
and  rise  of  temperature  to  101°  or  higher.  As  the  local  rigidity  dis- 
appears, the  enlarged  and  tender  gall-bladder  may  be  felt. 

In  the  most  acute  cases  the  onset  is  very  sudden,  with  rigors,  high 
temperature,  and  often  peritonitic  symptoms.  Chronic  cases  so  closely 
simulate  chronic  cholelithiasis  that  the  same  description  will  serve 
(see  p.  752). 

Diagnosis. — Gall-stones  and  acute  appendicitis  are  the  conditions 
most  likely  to  be  confused  with  cholecystitis.  In  the  former  the 
attacks  of  colic    are  more  sudden  and  pass  off  more  abruptly,  and 


GALL-STONE    DISEASE  743 

the  temperature  is  seldom  maintained  bo  high  as  in  cholecystitis.  In 
appendicitis  the  pain  is  lower,  vomiting  is  more  likely  to  be  promi- 
nent, and  breathing  is  not  interfered  with.  It  may  be  impossible  t<> 
differentiate  the  very  acute  cases  from  acute  pancreatitis,  intestinal 
obstruction,  or  pneumonia. 

Treatment.  The  milder  cases  may  completely  recover  on  test, 
limitation  of  diet,  and  the  exhibition  of  alkalis.  Persistent  tenderness 
with  fever,  or  obvious  enlargement  of  the  gall-bladder,  necessitates 
surgical  interference,  which  in  the  very  severe  cases  must  be  prompt. 
The  operation  will  usually  consist  in  drainage  of  the  gall-bladder. 
Cholecystectomy  adds  to  the  operative  risk,  and  fails  to  provide 
drainage  of  the  deeper  ducts,  and  is  therefore  not  generally  advisable. 

Cholangitis 

Cholangitis  is  nearly  always  associated  with  the  presence  of  gall- 
stones, and  it  may  persist  even  after  the  calculi  have  been  passed. 
The  ducts  are  full  of  bile-stained  pus. 

Clinical  features. — The  condition  may  be  preceded  by  the 
symptoms  of  gall-stones,  and  may  follow  directly  on  an  attack,  or  be 
ushered  in  by  a  rigor,  with  perhaps  uneasiness  about  the  hepatic 
region  ;  the  patient  feels  ill  and  generally  looks  poisoned,  and  is  more 
or  less  drowsy.  Chills  may  be  repeated  irregularly,  while  the  temperature 
between  them  is  either  a  little  raised  or  subnormal.  Jaundice  is  usual, 
but  not  invariable,  and,  if  well  developed,  probably  depends  on  some 
causative  obstruction.  The  liver  is  enlarged  and  tender,  and  the 
spleen  may  be  palpable.     The  disease  is  subject  to  remissions. 

Treatment. — Operation  for  calculi  is  unwise  during  an  attack 
of  cholangitis.  Free  purgation,  abundance  of  fluid  by  the  mouth, 
infusion  of  saline,  and  the  exhibition  of  urotropin  in  10-grain  doses 
are  the  most  useful  therapeutic  measures  ;  opium  should  be  studiously 
avoided.  If  improvement  does  not  follow,  the  ducts  must  be  drained, 
usually  through  the  gall-bladder. 

GALL-STONE   DISEASE 

Pathology ;  etiology. — Experimental  research  has  proved 
that,  though  mild  inflammation  due  to  attenuated  infections  is  a 
potent  etiological  factor,  a  virulent  infection  is  not  followed  by  calculus 
formation. 

When  gall-stones  cause  symptoms,  organisms,  especially  bacilli  of 
the  colon  group,  are  generally  found,  not  only  in  the  bile,  but  in  the 
calculi  themselves.  Their  presence  leads  to  a  mild  catarrh  of  the 
mucous  membrane,  and,  therefore,  to  an  increased  production  of 
cholesterin. 

According  to  Aschoff,  mere  stagnation  of  bile  in  the  gall-bladder, 


744 


GALL-BLADDER  AND   BILE-DUCTS 


without  an  infective  catarrhal  process,  may  lead  to  the  formation  of 
cholcsterin  stones  by  simple  deposition  from  the  bile.  When  infection 
is  added,  there  is  an  increased  production  of  cholesterin,  and  also  of 
calcium  salts,  which  are  deposited  on  the  cholesterin  nucleus.  These, 
in  conjunction  with  bile  pigment,  constitute  the  pigmented  calculi. 

Though  usually  formed  in  the  gall-bladder,  calculi  may  originate 
in  any  of  the  extrahepatic  or  even  intrahepatic  ducts.  Some  autho- 
rities state  that  very 
small  calculi  deposited  in 
the  ducts  may  be  washed 
into  the  gall-bladder  by 
the  normal  bile  current. 
The  gross  forms  gall- 
stones usually  take  are 
illustrated  in  Plate  99. 

As  a  rule,  no  nucleus 
can  be  found,  but  with- 
out doubt  small  gall- 
stones often  form  the 
centres  on  which  larger 
ones  are  built  (Fig.  523, 
a).  It  is  important  to 
recognize  that  unabsorb- 
able  ligatures  and  sutures 
may  later  form  the  start- 
ing-point of  calculi  (Fig. 
523,  b).  Inspissated  mu- 
cus, degenerated  epithe- 
lium, and  more  rarely 
masses  of  bacteria,  may 
constitute  a  nucleus  round 
which  bile  pigments,  etc., 
may  be  deposited. 
Pathological  consequences  of  gall-stones. — Gall-stones 
are  often  found  post  mortem  which  have  exhibited  no  previous 
evidence  of  existence,  but  they  may  cause  inflammation  and  sometimes 
obstruction. 

Inflammation  depends  on  organisms  which  may  be  similar  to 
those  associated  with  the  gall-stone  origin,  or  may  be  the  result  of  a 
secondary  invasion.     The  Bacillus  coli  is  most  frequently  found. 

In  slight  cases  or  very  early  stages  the  gall-bladder  may  show  very 
little  beyond  microscopic  changes  in  its  walls,  though  the  bile  may 
be  turbid  or  flocculent,  and  later  the  contents  may  become  purulent, 
forming  an  "  acute  empyema  of  the  gall-bladder."     After  a  time  the 


Fig. 


523. — Gall-stones,  showing  nuclei. 
(Actual  size.) 


a.  Calculus  from  I  he  common  duct.  The  quadrilateral  stone 
forms  the  nucleus  around  which  an  oval  stone  has  formed, 
this  in   turn  b.-ing  covered   by  amorphous  material. 

/■,  Calculus  from  tin:  gall-bladder,  a  catgut  suture  forming 
the  nucleus.  (From  a  specimen  kindly  lent  by  Hamilton 
Drumtiicmd.) 


5 


Varieties  of  gall-stones.     |  Actual  sizes.) 

1  and  3.  Clusters  of  calculi  as  ordinarily  met  with  in  the  gall-bladder. 

2,  The   very   small  type  of  gall-stone,  of  which  there  were  3.654  removed   from  a  case   of   acute  distension  of 

the  gall-bladder,  one  of  the  larger  stones  being  impacted  in  its  neck. 
4  and  5.   Examples  of  single  calculi  from  the  gall-bladder,  such  as  produce  ball-valve  obstructions. 

6.  A  calculus  which  was  impacted  in  the  ileum,  producing  acute  obstruction. 

7.  A  typical  stone  from  the  common  duct. 

8.  A  group   of   calculi    from  one  case:    (a)  from    the    gall-bladder,  (b)  from    the  right    hepatic    duct,  (c)  from 

the  common  duct,  (d)  from  the  common  hepatic  duct. 


Plate  99. 


GALL-STONI.    DISK  ASF. 


745 


mucous  membrane  is  reddened  and  t  he  whole  wall  thickened  (Kg.  524), 
while  still  later  there  may  be  ulceration  or  localized  gangrene,  though 
this  usually  only  occurs  when  obstruction  coexists.  Haemorrhage  may 
take  plaoe  into  such  an  inflamed 
gall-bladder.  When  the  inflamma- 
tion becomes  chronic  the  gall- 
bladder is  thickened  and  exhibits 
fibroid  changes,  while  the  contents 
are  in  most  cases  purulent,  forming 
"chronic  empyema  of  the  gall- 
bladder." 

Peritoneal  adhesions  commonly 
form  and  persist,  and  rarely  they 
may  cause  trouble. 

Obstruction  is  most  com- 
monly produced  by  the  impaction 
of  a  calculus  in  the  neck  of  the 
gall-bladder,  in  its  pelvis,  or  in 
the  first  compartment  of  the  cystic 
duct.  In  the  acute  cases  the  con- 
sequences depend  on  the  condition 
of  the  gall-bladder  at  the  time  of 
the  impaction.  If  its  contents  be 
infected,  the  viscus  rapidly  be- 
comes inflamed  and  acutely  dis- 
tended, and  its  peritoneal  coat 
soon  becomes  reddened  and  lymph- 
covered.  The  mucous  membrane 
ulcerates,  and  gangrene  may  super- 
vene (Plate  100)  and  lead  to  per- 
foration or  to  extensive  sloughings. 
An  inflamed  gall-bladder  usually 
acquires  adhesions  to  the  stomach, 
duodenum  (Fig.  525),  or  hepatic- 
flexure  of  the  colon.  It  may  sup- 
purate and  burst  into  one  of  the 
adherent  viscera,  or  more  rarely 
through  the  belly  wall,  leading  to 
the  formation  of  an  external  biliary 
fistula.  When  perforation  occurs  into  one  of  the  hollow  viscera, 
calculi  as  well  as  pus  may  thus  escape,  but  not  uncommonly  the 
calculus  is  of  the  large,  single  variety,  and  in  these  circumstances 
the  gall-bladder  contracts  upon  and  firmly  grasps  the  calculus,  no 
further  distension  occurring,  as  the  secreting  glands  in  its  wall  have 


Fig.  524. — Acute  inflammation  of 
the  gall-bladder,  following  im- 
paction of  a  calculus  in  its  neck. 


746  GALL-BLADDER  AND   BILE-DUCTS 

been  destroyed  by  the  inflammation.  Such  a  calculus,  tightly  grasped 
by  the  contracted  and  functionless  gall-bladder,  is  apparently  safely 
imprisoned,'  but  it  may  be  potent  for  evil,  for,  as  a  result  of  the  slow 
contraction  of  the  gall-bladder,  the  stone  may  be  constantly  pressed 
against  the  neighbouring  viscus  until  it  finally  erodes  through  into 
the  stomach  or  intestine.  Thus,  large  calculi,  capable  of  causing 
intestinal  obstruction,  may  find  their  way  into  the  bowel.  (Plate 
99,  (i,  and  Figs.  525  and  526.)  Moreover,  the  resulting  cicatrization  and 
adhesions  may  produce  pyloric  obstruction  or  hour-glass  stomach. 

When  the  obstruction  is  gradual,  or  the  contents  of  the  gall-bladder 
are  not  infected  at  the  time  of  impaction,  "  hydrops  "  of  the  gall- 
bladder ensues,  the  viscus  undergoing  gradual  distension  with  watery 
or  sometimes  inspissated  jelly-like  mucus,  and  its  wall  becoming  thinned 
without  inflammatory  changes.     (Fig.  527.) 

These  greatly  distended  gall-bladders  may  give  rise  to  little  incon- 
venience, but  they  may  be  ruptured  by  violence,  or  may  develop 
cholecystitis  due  to  secondary  infection  (p.  741).  A  hydrops  may 
also  result  from  an  acute  obstruction  with  infection,  the  latter  gradu- 
ally dying  down,  or  lighting  up  from  time  to  time,  but  always  with 
lessened  virulence.  Sometimes  relief  of  obstruction  alternates  with 
recurrences,  and  gives  rise  to  an  "  intermittent  hydrops." 

Gall-stones  in  the  ducts. — Calculi  either  reach  the  ducts  from 
the  gall-bladder,  after  which  they  probably  increase  in  size  (Fig. 
523,  a),  or  they  are  formed  in  the  ducts  themselves.  Commonly, 
they  give  rise  to  symptoms  from  obstruction,  and  to  this  infection 
may  be  superadded. 

Obstruction  is  due  to  the  size  of  the  stone,  the  resultant  contrac- 
tion of  the  duct,  and  the  associated  inflammatory  changes.  It  may 
be  temporary,  and  simply  lead  to  slight  dilatation  of  the  ducts  above, 
which  disappears  with  the  passage  of  the  stone  into  the  duodenum. 
Or  the  stone  may  act  like  a  ball  valve,  falling  back  into  the  dilated 
portion  of  the  duct  above,  only  to  be  forced  down  again  at  some  future 
time.  In  each  successive  attack  the  ducts  become  more  and  more 
distended. 

The  obstruction  is  seldom  complete  for  long,  and  such  a  calculus 
may  permit  free  passage  of  the  bile,  gaining  increment  by  gradual 
deposition  until  it  may  reach  the  great  size  sometimes  seen.  (Fig. 
523,  a.)  But  the  impaction,  though  rarely  absolute,  may  be  practically 
permanent ;  then  the  ducts  above  become  uniformly  dilated,  to  form 
large  channels  all  through  the  liver  (Fig.  528),  the  common  duct  itself 
being  sometimes  as  large  as  the  small  intestine  if  the  dilatation  is 
cylindrical,  or  like  a  huge  cyst  if  it  is  saccular. 

When  a  stone  is  impacted  near  the  lower  end  of  the  common  duct 
it  may  dilate  the  orifice  and  escape  into  the  intestine  per  vias  naturales, 


748 


GALL-BLADDER   AND   BILE-DUCTS 


but  more  usually  it  ulcerates  through  the  duct  and  bowel  wall  just 
above  the  duodenal  papilla  (Fig.  529). 

A  calculus  in  the  ampulla  of  Vater  may  obstruct  the  opening  and 
throw  the  bile  and  pancreatic  duct  into  a  continuous  channel ;  it 
is  then  a  potent  cause  of  pancreatitis.     (Fig.  519.) 

Remote  consequences  of  gall-stones.  —  Fistulae  may 
be    external    or    internal  ;     spontaneous    or    the    result    of    surgical. 


interference ;  con- 
stant or  recur- 
ring ;  and  biliary 
or  mucoid  or 
muco-purulent. 

External  fis- 
tulas, when  spon- 
taneous, almost 
invariably  depend 
on  suppuration  of 
the  gall-bladder 
associated  with 
an  obstruction  in 
the  cystic  duct. 
They  usually  open 
just  above  the 
umbilicus,  but 
sometimes  appear 
over  the    normal 

situation   of  the   gall-bladder,   in  the   iliac    fossa,  the   loin,  or    even 
between  the  lower  ribs. 

External  fistulae,  secondary  to  surgical  interference,  may  be  mucoid 
or  biliary.  In  the  former,  either  an  obstruction  in  the  cystic  duct  has 
been  overlooked,  or  the  gall-bladder  has  been  fixed  to  the  skin  of  the 
abdominal  wall  instead  of  to  the  peritoneum.  The  latter  depend  upon 
some  obstruction  remaining  in  the  common  duct,  due  to  calculus^ 
stricture,  or  involvement  by  pancreatitis. 


r  --  ,v 

Fig.  526. — The  first  part  of  the  duodenum  is  laid 
open,  showing  a  large  opening  into  the  gall- 
bladder, which  is  occupied  by  a  faceted  calculus. 
Lying  free  in  the  bowel  is  the  sister  calculus, 
which  became  impacted  in  the  ileum  and  caused 
the  death  of  the  patient  from  acute  obstruction. 
The  facets  on  the  two  calculi  exactly  correspond. 

{From  a  specimen  in  the  Museum  of  the  University  of  Durham 
College  of  Medicine.) 


/ 


\ 


Fig.  527.— Chronic  distension  of  the  gall-bladder  (hydrops) 
from  impaction  of  a  calculus  in  its  neck. 


749 


750 


GALL-BLADDER   AND   BILE-DUCTS 


The   treatment   is   expectant    if  the   obstruction  is   certainly   only 
temporary,   as  in  pancreatitis.     An    obstruction  may  be  removed  or 


Fig.  528. — Dilatation  of  the  bile-ducts  throughout  the  liver,  the  result 
of  long-continued  calculous  obstruction.  Cholecystenterostomy  had 
been  performed  with  the  Murphy  button. 

cholecystenterostomy  performed ;  or  an  attachment  of  the  gall-bladder 
to  the  skin  may  be  separated  and  the  viscus  closed  by  suture. 


(JALL-STONK    DISEASE 


75  • 


Internal    fistulas   are   probably   oommoner    than    external,    bul 

remain  unrecognized  owing  to  I  heir  Erequenl  lack-  of  symptoms.  They 
usually  pasa  between  the  gall-bladder  and  the  stomach,  duodenum,  <>r 
colon,  but  they  may  be  between  the  gall-bladder  and  the  kidney, 
the  lung,  or  even  the  bladder  or  uterus. 

Stricture  of  the  ducts.— This  condition  is  only  common  in  the 
cystic  duct,  where  it  frequently  follows  the  impaction  of  a  calculus. 
It    is  best   treated  by  cholecystectomy. 


Fig.  529. —Diagrams  made  from  actual  specimens  of  calculi  in 
the  common  duct. 

a.  Calculus  impacted  in  the  pancreatic  portion  of  the  duct,  in  a  position  suitable  for  removal  by 

transduodenal  choledochotomy. 

b.  Showing  how  a  calculus  impacted  in  the  same  situation  has  ulcerated  into  the  duodenum, 

the  papilla  remaining  intact. 

In  the  common  duct  stricture  is  much  more  important,  but,  for- 
tunately, rarer.  It  usually  follows  long  impaction  of  a  calculus,  and 
presents  the  symptoms  of  obstructive  jaundice  with  or  without  attacks 
of  pain. 

Treatment. — Plastic  restoration  of  the  duct  may  be  possible,  but 
in  most  cases,  if  the  gall-bladder  is  available  for  the  purpose,  chole- 
cystenterostomy  is  the  wiser  procedure. 


752  GALL-BLADDER  AND   BILE-DUCTS 

Intestinal  obstruction  in  connexion  with  gall-stones  may  be 
due  to  (a)  impaction  of  a  calculus  in  the  lumen  of  the  bowel ;  (b)  adhe- 
sions or  deformity  associated  with  an  internal  biliary  fistula  ;  (c) 
involvement  of  the  hepatic  flexure  of  the  colon  by  an  inflamed  gall- 
bladder. 

Clinical  features  of  gall-stone  disease — Gall-stones  are 
probably  three  or  even  four  times  as  common  in  the  female  as  in  the 
male  sex,  and,  on  the  average,  begin  to  cause  trouble  at  about  the 
age  of  35.  In  many  cases  they  are  quiescent  for  long  periods  ;  in 
others  they  only  cause  indefinite  symptoms,  such  as  "  indigestion," 
or  "  windy  spasms,"  often  erroneously  attributed  to  other  causes. 
Jaundice  is  infrequent  in  cholelithiasis. 

The  symptoms  that  gall-stones  may  cause  are  pain,  tenderness, 
nausea  and  vomiting,  and  jaundice,  to  which  may  be  superadded  the 
symptoms  of  infection.  The  physical  signs  are  those  of  local  peritonitis, 
with  or  without  enlargement  of  the  gall-bladder. 

Pain  may  or  may  not  take  the  form  of  "  an  attack  of  colic."  Colic 
starts  abruptly  in  the  epigastrium  or  right  hypochondrium,  frequently 
after  a  meal  and  usually  during  the  daytime.  The  onset  may  be 
accompanied  by  collapse,  vomiting,  and  profuse  perspiration.  The 
pain  may  be  agonizing,  doubling  the  patient  up,  but  after  a  time,  vary- 
ing from  a  few  minutes  to  several  hours,  it  passes  off,  leaving  the 
patient  exhausted  and  sore.  Other  patients  suffer  from  dull  aching 
or  sharp  pains  in  the  liver  region,  usually  aggravated  by  food  and 
relieved  by  vomiting.  The  pain  may  be  referred  to  the  back,  shoulder, 
neck,  front  of  chest,  or  down  the  arm.  During  an  attack  there  may  be 
rigidity  of  the  whole  abdomen,  especially  marked  in  the  upper  right 
quadrant,  which  is  excessively  tender.  The  tenderness,  at  first  super- 
ficial, later  is  only  elicited  by  deep  pressure,  or  better  by  Naunyn's 
test,  which  depends  on  the  inability  of  the  patient  to  take  a  full  inspira- 
tion while  the  examining  fingers  press  deeply  down  beneath  the  right 
costal  arch.  Sometimes  tenderness  is  found  posteriorly,  two  or  three 
finger-breadths  from  the  10th  to  the  12th  dorsal  spines,  either  alone  or 
with  the  anterior  tenderness. 

Nausea  and  vomiting  may  occur  independently  of  pain.  Nausea 
is  often  extreme.  When  vomiting  occurs  it  is  at  first  of  greenish, 
watery  fluid,  but  afterwards  no  bile  is  seen,  merely  watery  fluid  and 
mucus. 

Jaundice  is  found  only  in  about  20  per  cent,  of  all  cases,  and 
even  with  stones  in  the  common  duct  only  in  33J  per  cent.  When 
definite  and  long-continued,  it  depends  on  impaction  of  a  stone  in  the 
common  duct ;  when  slight  and  transient,  it  may  result  from  catarrh 
associated  with  obstruction  in  the  cystic  duct.  In  any  case,  this 
symptom  does  not  appear  until  the  day  after  the  attack,  but  if  the 


GALL-STONE    DISEASE  753 

block  is  in  the  oommon  duct  it  may  afterwards  vary  from  day  to  day, 
until  ir  either  disappears  or  gradually  assumes  an  olive-green  tint. 
Even  with  recenl  and  slight  jaundice,  severe  bleeding  may  follow  any 
wound,  ami  in  long-standing  cases  spontaneous  hsemorrhag*  cur. 

Itching  is  anol  her  very  dial  pmptom. 

Slight  fever  occurs  apart  from  any  marked  infection,  and  insta- 
bility of  temperature  is  almost  characteristic  of  gall-stones.  A  high 
temperature  or  repeated  rigors  Buggesl  severe  infection.  Stones  in 
the  common  duel  and  bile  infection,  ague-like  paroxysms  with  rig< 
and  temperature  running  up  to  104°  or  105°  and  as  suddenly  coming 
down,  make  up  the  clinical  picture  of  Charcot's  "'  intermittent  hepatic 
Eever." 

General  symptoms  such  as  depression  and  anorexia,  with  sour 
breath  and  coated  tongue,  are  invariably  accompaniments.  There 
may  be  considerable  abdominal  distension  and  marked  constipation. 
S.metimes  gall-stones  are  found  in  the  fanes. 

Local  physical  signs. — Rigidity  of  the  upper  segment  of 
the  right  rectus  and  deep  tenderness  have  already  been  mentioned. 
The  presence  of  a  local  tumour,  when  discoverable,  is  important. 
Generally,  this  tumour  is  the  distended  gall-bladder  (Fig.  519),  perhaps 
augmented  by  surrounding  inflammatory  complications  ;  but  some- 
times an  inflammatory  mass  around  the  common  duct,  or,  rarely,  even 
a  mass  of  stones,  may  be  felt. 

A  palpable  gall-bladder  appears  as  a  smooth,  rounded,  pear-shaped 
tumour  which  moves  up  and  down  with  respiration,  cannot  be  held 
down,  is  continuous  with  the  liver  above,  and  can  be  slightly  rocked 
from  side  to  side.  When  such  a  gall-bladder  enlarges,  it  usually  does 
so  in  a  direction  downwards  and  inwards  towards  the  umbilicus,  but 
quite  commonly  it  enlarges  directly  downwards  and  may  even  reach 
the  right  iliac  fossa.  Just  after  an  attack  the  gall-bladder  is  usually 
tender,  and  this  may  persist,  but  chronic  enlargements  are  neither 
painful  nor  tender. 

The  cases  as  seen  by  the  surgeon  may  be  arranged  in  the  following 
groups  : — 

1.  Acute  cases  without  jaundice. — There  is  sudden  onset  with 
severe  pain,  general  disturbance,  and  elevation  of  temperature.  At 
first  the  right  hvpochondrium  is  rigid  and  tender,  but  at  a  later  stage 
the  enlarged  gall-bladder  may  be  easily  felt.  The  neck  of  the  gall- 
bladder or  the  cystic  duct  will  be  found  blocked  by  a  calculus. 

2.  Acute  cases  with  jaundice. — The  jaundice  follows  an  attack 
of  colic,  and  there  is  much  general  disturbance,  often  with  rigors. 
The  right  hvpochondrium  is  tender  and  rigid,  but  at  no  stage  can  the 
gall-bladder  be  felt.     A  calculus  is  impacted  in  the  common  duct. 

3.  Quiescent  (interval)  cases  without  jaundice — The  patient 

2    7/i 


754  GALL-BLADDER   AND   BILE-DUCTS 

may  suffer  from  vague  abdominal  discomfort,  or  may  be  entirely  free 
from  symptoms,  with  merely  the  history  of  an  attack.  The  gall-bladder 
may  be  felt  distended  or  there  may  be  simply  deep  tenderness.  There 
are  stones  in  the  gall-bladder  or  common  duct  or  both. 

4.  Quiescent  (interval)  cases  with  jaundice.— The  patient 
has  the  general  symptoms  of  jaundice.  The  gall-bladder  is  not  en- 
larged though  the  liver  may  be  palpable.  There  are  stones  impacted 
in  the  common  duct. 

Diagnosis — If;  after  an  attack  of  pain  in  the  upper  abdomen, 
the  enlarged  and  tender  gall-bladder  can  be  felt,  or  there  is  definite 
tenderness  over  the  region  of  the  gall-bladder  or  common  duct,  the 
diagnosis  of  gall-stones  is  straightforward.  In  the  absence  of  these 
signs  the  diagnosis  may  have  to  be  made  from  the  history  alone.  When 
there  is  colic,  the  abrupt  seizures,  the  nausea  and  vomiting,  and  the 
-lrivering  are  most  suggestive.  In  cases  without  colic,  the  constant 
local  discomfort  with  shivering,  and  the  alternation  of  soreness  with 
periods  of  complete  relief,  distinguish  the  trouble  from  gastric  or 
duodenal  ulcer.  Marked  shivering,  constant  slight  jaundice,  and 
wasting  suggest  lodgment  of  calculi  in  the  common  duct,  without 
impaction,  so  that  most  of  the  bile  escapes  into  the  bowel.  Chronic 
jaundice,  varying  in  intensity,  and  free  from  an  olive-green  tint, 
associated  with  attacks  of  colic,  is  in  favour  of  gall-stones.  The  com- 
bination of  distension  of  the  gall-bladder  with  obstructive  jaundice 
renders  the  diagnosis  of  gall-stones  improbable  (C'ourvoisier's  law). 
(Fig.  519  and  Plate  102.) 

The  prognosis  is  very  uncertain.  Gall-stones  are  always 
dangerous.  Acute  obstruction  may  develop  in  the  first  attack,  and 
proceed  to  gangrene,  perforation,  and  peritonitis  ;  or  countless  attacks 
of  colic  may  culminate  in  the  passage  of  all  the  -tones,  perhaps  after 
vears  of  suffering  ;  or,  not  infrequently,  malignant  disease  or  pan- 
creatitis may  supervene. 

Treatment. — Unless  some  condition,  such  as  diabetes,  extreme 
obesity,  or  cardiac  or  renal  disease,  renders  operation  unduly  danger- 
mis,  gall-stones  should  be  removed  as  soon  as  diagnosed. 

Palliative  treatment  during  an  attack  consists  in  enjoin- 
ing absolute  starvation.  Excessive  nausea  or  vomiting  demands 
gastric  evacuation  and  lavage  with  an  alkali.  Pain  may  be  alleviated 
hv  hot  poultices  over  the  hepatic  region,  while  thirst  may  be  relieved 
and  eUmination  stimulated  by  the  rectal  administration  of  a  pint  of 
half-strength  saline  every  four  hours.  This  plan  will  often  obviate 
the  necessity  for  morphia,  with  advantage  to  the  rapidity  of  recovery 
and  the  subsequent  condition  of  the  patient.  Between  the  attacks. 
if  operation  is  not  to  be  undertaken,  ample  e.v  bundant  drinks 

of  water,  and  gentle  but  efficient  laxatives  should  be  advi-ed. 


OPERATION    FOR  GALL-STONES 


755 


Operative  treatment.  The  time  to  operate. — An  inter- 
val between  attacks  should  be  chosen,  unless  spreading  inflammation, 
acute  pancreatitis,  or  sudden  perforation  and  acute  peritonitis  demands 
immediate  operation.  Even  in  the  presence  of  localized  suppuration 
some  preparation  is  usually  advisable,  and  long-continued  jaundice 
requires  a  period  of  probation  owing  to  the  danger  of  hemorrhage 
and  of  toxsemia. 

Preliminary  treatment. — Obesity  should  be  reduced  by  the 
prohibition  of  starches,  sugars,  and  fats,  combined  with  free  purga- 
tion and  abdominal  massage. 
In  the  presence  of  jaundice 
or  symptoms  of  cholangitis, 
thorough  clearance  of  the 
alimentary  canal  and  the 
liberal  use  of  saline  solution 
with  small  doses  of  urotro- 
pine  are  the  most  valuable 
preparatory  measures.  To 
obviate  the  hemorrhagic 
tendency,  calcium  chloride 
has  been  much  vaunted,  but 
its  value  is  doubtful ;  a  far 
better  method  is  the  free 
flushing  of  the  system  with 
normal  saline.  Bleeding  has 
also  been  prevented  and 
checked  by  alien  serums ; 
fresh  horse  or  rabbit  serum  is 
best,  ox  serum  being  unsuit- 
able.  Antidiphtheritic  serum  FJg  530>_Incisions  used  in  gall-bladder 
is  often  the  readiest  to  hand,  surgery.  The  vertical  incision  is  that 
and  may  be  given  subcuta-  usually  employed.  The  transverse  is 
neouslyor  intravenously  in  recommended  by  Rutherford  Morison. 
doses  of  10  to  30  c.c. 

The  operation In  acute  gall-stone  conditions,   ether  by  the 

open  method  affords  the  safer  anaesthesia  owing  to  the  risk  of  aceton- 
uria  after  chloroform. 

A  convenient  incision  is  a  vertical  one  extending  4  in.  downwards 
from  the  costal  margin,  through  the  outer  half  of  the  right  rectus 
muscle.  Freer  access  may  be  gained  by  carrying  the  cut  upwards  and 
inwards  to  the  costo-xiphisternal  notch  (Robson) ;  and  still  further 
room  can  be  obtained  by  adding  a  similar  extension  obliquely  outwards 
below  (Bevan)  (see  Fig.  530).  The  deeper  ducts  can  be  brought  nearer 
the  surface  by  placing  a  long,  narrow  sand-bag  transversely  beneath 


GALL-BLADDER   AND   BILE-DUGTS 


the  lower  thoracic  region.  Then  by  drawing  on  the  gall-bladder,  lifting 
forward  the  liver  and  rotating  it  on  its  transverse  axis,  the  surgeon 
can  straighten  out  the  ducts  and  approximate  the  deeper  parts  still 
further  to  the  surface.     The  operator  must  remember  to  remove  the 

sand  -  bag  before 
attempting  to  su- 
ture the  wound.  A 
transverse  incision 
may  be  used  in- 
stead ;  this  affords 
excellent  exposure 
of  the  gall-bladder, 
ducts,  and  hepatic- 
pouch  (Fig.  531). 
Before  opening  the 
gall-bladder,  care- 
ful examination 
must  be  made  of 
the  whole  biliary 
apparatus,  and  of 
the  liver,  pylorus, 
duodenum,  pancre- 
atic head,  and  he- 
patic flexure.  The 
ducts  are  palpated 
by  passing  the 
fingers  along  the 
right  side  of  the 
gall-bladder,  over 
its  neck,  down  the 
cystic  duct,  and 
through  the  fora- 
men of  Window. 
Here  the  common 
duct  can  be  felt 
between  the  fingers 
behind  and  the 
thumb  in  front  of 
the  gastro-hepatic 
omentum.  The 
lower  parts  of  the 
duct  must  be  felt 
for  through  the  duodenal  wall.  Finally,  the  hepatic  ducts  are  to 
be    explored    right   up   to   the  liver.    It   must  be   remembered  that 


Fig.  531. — Exposure  obtained  by  the  transverse 
incision  for  gall-stones  advocated  by  Rutherford 
Morison. 

i ...  Liver  ;  i>..  duodenum  :  c.r..,  gall-bladder  :  L.O.,  free  edge  of  lesser 

omentum  ;  (...  a  gauze  pack.     'I  he  fingers  of  the  operator  are  in  the 

foramen  of  Winslow,  steadying   and    thrusting    forward    the   lessei 

omentum,  while  the  thumb  is  free  to  palpate  the  common  duct. 

VIed.Joum.,  Nov.  8,  !<}<>-■:  6y  permission  of the  Editor  and 
of  Professor  Rutherford  Moriso    ) 


OPERATION    FOR   GALL-STONES  757 

sometimes,  id  a  very  tense  gall-bladder,  small  calculi  cannol  be  f •  -1  t  ; 
ilso  thai  enlarged  glands  near  the  neck  of  the  gall-bladder  and  at 
the  junction  of  the  cystic  and  common  ducts  may  be  mistaken 
for  calculi.  After  removal  of  the  stones,  another  examination  of 
the  ducts  is  necessary  to  ensure  that  no  calculi  have  been  overlooked. 
in  every  case  the  interior  of  the  gall-bladder  should  be  carefully 
explored  by  the  surgeon's  finger. 

Before  opening  the  viscus  the  rest  of  the  abdomen  must  be  shut 
ott  by  gauze-packing.  The  subsequenl  steps  depend  on  the  conditions 
found.  If  calculi  are  found  only  in  the  gall-bladder,  are  free,  and  not 
associated  with  inflammatory  signs,  they  should  be  removed,  and  the 
gall-bladder  should  then  be  drained  (cholecystostomy).  Cholecyst- 
endesis,  by  which  the  opening  in  the  viscus  is  sutured  and  the 
abdomen  closed,  perhaps  with  a  small  drain  down  to  the  sutured 
gall-bladder,  is  generally  inadvisable,  for  it  makes  no  provision  for 
the  escape  of  a  possibly  overlooked  tiny  stone,  or  for  drainage  of 
the  infected  biliary  canal. 

In  cholecystostomy  a  drainage-tube  is  fastened  into  the  open  gall- 
bladder by  an  invaginating  sero-muscular  purse-string  suture  of  No.  1 
chromicized  catgut,  placed  f  in.  from  the  cut  edge,  and  the  fundus 
is  then  fixed  to  the  parietal  peritoneum.  In  simple  cases,  with  free 
flow  of  bile,  the.  tube  may  be  removed  in  from  four  to  seven 
days. 

If  calculi  are  impacted  in  the  neck  of  the  gall-bladder  or  in  the  cystic 
duct,  with  or  without  suppuration  or  gangrene,  an  attempt  must  be  made 
to  dislodge  them  back  into  the  viscus  with  the  fingers  working  from 
outside.  The  gall-bladder  must  then  be  opened,  its  contents  removed, 
and  the  interior  carefully  dried  with  a  strand  of  gauze.  If  bile  at 
once  flows,  the  duct  is  free,  but  in  inflammatory  conditions  the  thicken- 
ing may  delay  the  appearance  of  bile  for  some  days.  In  acute  con- 
ditions, the  .surgeon  need  not  fear  for  the  ultimate  patency  of  the  duct, 
and  may  perform  cholecystostomy;  but  in  chronic  cases,  if  bile  does 
not  flow,  he  must  assure  himself  that  the  duct  is  patent,  or  he  must 
remove  the  gall-bladder  (cholecystectomy). 

If  the  obstructing  calculus  cannot  be  removed  by  manipulation, 
an  incision  may  be  made  directly  over  it  (cysticotomy),  or  removal 
of  the  gall-bladder  may  be  necessary.  In  cases  of  great  urgency  the 
gall-bladder  may  simply  be  drained,  and  if  the  calculus  does  not 
come  away  it   may   be   removed  at   a   second  operation. 

When  inflamed  and  suppurating  the  gall-bladder  and  its  surround- 
ings are  very  vascular,  and  its  removal  may  be  attended  by  trouble- 
some haemorrhage.  In  these  circumstances  excision  is  much  more 
dangerous  than  simple  drainage. 

The  same  remarks  apply  to  gangrene  of  the  gall-bladder.     This 


758 


GALL-BLADDER  AND   BILE-DUCTS 


is  rarely  total,  and  nearly  always  first  reaches  trie  peritoneal  surface 
at  the  fundus  (Plate  100).  In  most  cases  drainage  is  safest  and  best  ; 
in  a  few  the  fundus  only  may  be  excised  ;  and,  even  for  total  gan- 
grene, ample  drainage  and  isolation  by  gauze  packing  is  probably  the 
wisest  course,  for  in  these  cases  the  shortest  possible  operation,  with 
little  loss  of  blood,  is  essential. 

If  the  gall-bladder  is  firmly  adherent  to  surrounding  structures  as  the 
result  of  chronic  inflammation,  it  may  be 
impossible  even  to  see  the  viscus  until 
the  adhesions  are  separated.  To  avoid 
peritonitis  or  fistula,  great  care  is  ne- 
cessary hi  separating  the  stomach,  duo- 
denum, or  colon,  for  where  the  gall- 
bladder has  leaked  into  these  viscera 
communications  frequently  exist.  After 
exposure,  these  densely  adherent  gall- 
bladders are  often  found  to  be  quite 
small  and  closely  contracted  on  a  mass 
of  stones.  They  are  frequently  very 
thick-walled,  and  often  white  and  shiny 
(Pig.  532).  Such  gall-bladders  should  be 
removed,  for  a  certain  proportion  of 
them  turn  out  to  be  the  seat  of  malig- 
nant disease. 

Sometimes  the  greater  part  of  the 
gall-bladder  has  been  destroyed,  only 
the  neck  and  cystic  duct  remaining. 
After  removal  of  the  calculus,  a  tube 
must  be  led  out  from  the  duct  and  the 
cavity  walled  off  by  gutta-percha  tissue 
or  gauze.  The  omentum  is, useful  as  a 
covering  for  the  involved  area. 

Cholecystectomy. — The  removal  of  a 
moderate-sized  gall-bladder,  if  the  region 
of  the  cystic  duct  is  free,  may  be  com- 
menced by  catching  and  dividing  the  cystic  artery  and  duct,  and  then 
separating  the  gall-bladder  from  the  liver  from  below  upwards.  A 
very  large  viscus  must  sometimes  be  emptied  to  secure  a  view  of  the 
region  of  the  neck.  When  the  gall-bladder  is  shrivelled,  or  when 
the  parts  about  its  neck  are  obscured  (Fig.  o'2o),  then  it  is  best  to 
separate  the  organ  from  the  liver  as  a  first  step,  and  to  use  it  as 
a  tractor  while  the  cystic  duct  and  artery  are  carefully  exposed. 

As  a  rule,  the  gall-bladder  is  not  removed  when  drainage  of  the 
ducts  is  necessary,  but  if  thought  desirable  a  tube  may  be  brought 


Fig.  532. — Chronically  in- 
flamed and  thickened 
gall-bladder  with  cal- 
culi. Such  a  gall-bladder 
is  often  the  seat  of 
malignant  disease. 


Acute  cholecystitis,  the  result  of  calculous  obstruction  of  the  cystic 
duct.  There  was  extensive  gangrene  of  the  mucous  membrane, 
which  had  extended  to  the  peritoneum  at  the  fundus.    (Actual  size.) 


Plate  100. 


OPERATION    FOR   GALL-STONES 

out  from  the  end  of  the  duct.    In  any  case,  it  is  wise  to  insert  a  small 
tube  down  to  the  region  of  the  divided  and  ligatured  duct.    The  caw 

i  on  the  liver  may  sometimes  be  covered  with  peritoneum  reflected 
from  the  Bides  of  the  gall-bladder,  but  any  oozing  from  it  must  be 
treated  by  _  itize  packing. 

If  calculi  "/'    prei  both  gall-bladder  and  common  duct,  they 

can  but  rarely  be  pushed  from  the  duct  into  the  gall-bladder,  and, 
therefore,  this  condition  necessitates  the  opening  of  both.  The  duct 
should  be  opened  first,  the  intact  gall-bladder  being  a  useful  tractor. 
The  calculi  may  be  free  in  the  duct  or  impacted  in  the  lowr  end. 
Whenever  possible,  the  calculi  should  be  pushed  into  the  supraduodenal 
portion  of  the  duct,  which  can  be  .safely  opened  and  the  stones  remoi 
Direct  drainage  of  the  common  duct  is  usually  advisable.  The  stones 
are  now  removed  from  the  gall-bladder,  which  may  be  afterwards 
closed  if  healthy,  or  may  require  to  be  separately  drained. 

Calculi  impacted  in  the  lower  end  of  the  duct  may  rarely  be  pushed 
on  into  the  duodenum,  or  pushed  back  into  the  duct  above,  but,  as  a 
rule,  the  duct  must  either  be  opened  behind  the  duodenum  or  by  the 
transduodenal  route  (Fi.tr.  529,  a).  When  calculi  are  also  present  in 
the  hepatic  ducts  they  may  be  forced  down  into  the  common  duct,  or 
removed  by  direct  incision,  or  broken  up  and  extracted  in  fragments. 

If  any  doubt  exist  as  to  the  complete  removal  of  the  fragments, 
not  only  must  ample  external  drainage  be  provided,  but  a  good-sized 
metal  probe  must  be  passed  from  the  duct  into  the  duodenum,  so 
dilating  the  papilla  that  the  fragments  may  pass. 

After-treatment.— If  vomiting  be  troublesome,  a  pint  of 
hot  water  should  be  drunk  ;  and  if  this  fail,  the  stomach  should  be 
washed  out.  Even  in  the  absence  of  vomiting,  eructation  of  mouth- 
fuls,  or  hiccup  with  fullness  and  epigastric  distress,  demands  gastric 
lavage,  repeated  if  necessary  ;  for  these  symptoms  may  be  premoni- 
tory of  acute  dilatation  of  the  stomach,  a  very  grave  complication. 

The  rectal  injection  of  half-strength  normal  saline  should  be  used 
in  all  but  the  simplest  cases,  for  it  combats  any  tendency  to  shock, 
relieves  thirst,  and.  most  important  of  all,  greatly  aids  elimination. 

Results  of  operations. — The  removal  of  gall-stones  that 
have  not  left  the  gall-bladder  or  set  up  dangerous  complications 
should  not   i  mortality  of  more  than  2  per  cent.;    and  even 

taking  all  gall-stone  operations  together  the    death-rate  is  probably 
but  5  per  cent. 

The  percentage  of  recurrences  in  simple  cases  is  small  (not  more 
than  2  or  3  per  cent.),  but  it  rises  pari  passu  with  increasing  complica- 
tions. There  is  not  yet  sufficient  evidence  to  show  which  type  of 
operath  :id.     Cholecystostomy  appears  to  have  been 

attended  by  a  large  proportion  of  recurrences,  but  this  operation  has 


760 


GALL-BLADDER   AND   BILE-DUCTS 


often  to  be  used  when  there  is  infection  of  the  deeper  ducts.  It  is 
important  to  recognize  that  recurrence  takes  place  after  complete 
removal  of  the  gall-bladder.  Overlooked  malignant  disease  or  pro- 
gressive pancreatitis  may  lead  to  disappointing  results  after  otherwise 
successful  operations. 

NEW 
GROWTHS 

Simple  growths 
of  the  gall-bladder 
and  ducts  are  very 
rare;  fibroin  as, 
lipomas,  and  cys- 
tic adenomas  have 
been  met  with  ; 
papillomas  are  the 
must  frequent,  but 
here  apparently 
they  are  not  so 
closely  associated 
with  cancer  as 
elsewhere. 

Carcinoma  of 
the  Gall- 
bladder 

Etiology. 

— In  over  80  per 
cent.  of  cases 
gall-stones  and 
cancer  are  asso- 
ciated. Cancer 
is  commoner  in 
women  than  in 
men  in  the  same 
sex  proportion 
as  calculi.  The 
average  age  is 
just  over  50,  the 
disease  being  un- 
common before 
i0  years. 

Morbid 
anatomy. — The  disease  is  met  with  in  three  forms  :  (1)  As  a 
definite  localized  tumour,  usually  at  the  fundus,  though  sometimes  in 
the  body,  producing  an  hour-glass  constriction,  or  at  the  neck, 
causing   obstruction   (Fig.   533) ;   (2)  as  a  diffuse  thickening  of   the 


Fig.  533. — Primary  carcinoma  of  the  gall-bladder 
producing  hour-glass  deformity,  and  involving  the 
liver  by  direct  extension.  (Actual  size.)  Case 
of  successful  excision  by  Rutherford  Morison. 


CARCINOM  \    OF   G  M.I.HI.  A  I  >l  )l  K 


;6i 


whole  \\iill  oi  the  gall  bladder,  which  is  white,  glistening,  and  tightly 
contracted  on  a  mass  <>i  calculi  (Fig.  532);  (3)  rarely  as  .1  [ungating 
growth,  rilling  the  gall-bladder 
and  perhaps  causing  haemor- 
rhage (Fig.  534). 

Microscopically,  the  grov<  th  is 
usually  columnar  or  spheroidal- 
celled.  It  tends  to  spread  dow  d 
the  ducts  and  to  involve  1  he 
liver  by  direct  extension ;  later 
it  may  extend  to  the  colon, 
duodenum,  or  peritoneum. 

Clinical  features — The 
early  history  is  usually  that  of 
cholelithiasis,  gradually  followed 
by  long-continued  illness,  with 
constant  hepatic  pain  and  pro- 
gressive emaciation,  dispropor- 
tionate to  gall-stone  disease. 
Jaundice  appears  late  in  about 
half  the  cases. 

Physical  signs  may  be 
entirely  absent,  or  there  may 
be  a  hard,  nodular  tumour  in 
the  gall-bladder  region. 

Diagnosis.  —  Gall-stones, 
especially     with     inflammatory 
complications,  malignant  disease 
of  the  liver,  carcinoma  of  the 
stomach  adherent  to  the  liver, 
or    a    growth    in    the    hepatic 
flexure,  most  commonly  lead  to 
confusion.      The    history 
and  symptoms  rather  than 
the    physical     signs     are 
likely  to  aid  in    differen-        /A 
tiation. 

Prognosis.  —  Death 
usually  occurs  within  six 
months. 

Operative     treat- 
ment.—  Unless  the  pre- 
sence   of    unequivocal   secondary   deposits  renders   operation  useless, 
exploration   should  always  be  made,  for  inflammatory  masses  may 


Fig.  534.—  Carcinoma  of  the  gall-bladder 
of  the  fungating  type.  The  viscus  was 
greatly  distended  with  haemorrhage.' 
(Actual  size.) 


762  GALL-BLADDER   AND   BILE-DUCTS 

closely  simulate  cancer.  The  diagnosis  confirmed,  and  the  possibility 
of  complete  clearance  ascertained,  the  surgeon  should  freely  remove 
the  gall-bladder,  with  a  wedge  of  healthy  liver  tissue. 

Direct  extension  to  the  liver  does  not  necessarily  preclude  successful 
operation,  but  careful  examination  is  required  to  determine  the  absence 
of  associated  secondary  deposits  in  that  organ.  If  complete  excision 
be  impossible,  operation  should  be  abandoned,  for  the  mere  removal  of 
calculi  never  does  good.  Even  in  apparently  favourable  cases,  early 
recurrence  in  the  liver  or  peritoneum  is  very  frequent.  Cases  in  which 
a  chronically  inflamed  gall-bladder  is  found  microscopically  to  harbour 
cancer  present  better  results. 

Carcinoma  of  the  Bile -Ducts 

Primary  malignant  disease  of  the  bile-ducts  occurs  more  frequently 
than  is  supposed.  The  disease  differs  from  cancer  of  the  gall-bladder 
in  that  it  is  usually  without  gall-stones,  and  that  males  are  more 
commonly  affected  than  females,  though  it  occurs  at  the  same  period 
of  life, 

Pathology.— The  growth  may  affect  any  duct,  but  usually 
attacks  one  or  other  end  of  the  common  duct.  It  forms  a  columnar- 
celled  carcinomatous  ring  and  appears  as  a  stony,  hard,  white  nodule, 
not  larger  than  a  cherry,  easily  mistaken  for  a  calculus.  Obstruction 
is  absolute,  the  ducts  above  become  greatly  dilated  and  the  liver  bile- 
logged,  death  occurring  from  cholaemia  or  cholangitis. 

Clinical  features — Jaundice  commences  insidiously  and  gra- 
dually deepens  without  intermissions  until  the  skin  may  assume  a 
dark  bronzed  or  olive-green  tinge.  Pain  is  inconstant  ;  there  may  be 
an  attack  of  colic,  but  this  is  seldom  repeated.  There  are  no  physical 
signs  beyond  enlargement  of  the  liver,  and  of  the  gall-bladder  when 
the  common  duct  is  involved. 

The  diagnosis  is  suggested  by  painless,  persistent,  and  other- 
wise unexplained  jaundice  in  a  patient  between  50  and  60.  Gall-stone 
obstruction  is  nearly  always  attended  by  a  history  of  repeated  attacks 
of  pain  and  sudden  onset ;  cancer  of  the  pancreatic  head  may  be 
palpal  tie.  or  may  be  indistinguishable  ;  while  catarrhal  jaundice  so 
surely  clears  up  as  to  render  diagnosis  certain. 

Prognosis. — Death  inevitably  occurs  from  cholaemia,  haemor- 
rhage, or  infection,  in  from  six  months  to  a  year  from  the  onset. 

Treatment. — It  may  be  possible  to  excise  the  growth,  either 
with  end-to-end  union,  implantation  into  the  peritoneal  surface  of  the 
duodenum,  or  ligature  of  both  ends  and  cholecystenterostomy.  Gener- 
ally, however,  cholecystenterostomy  without  excision  will  be  the  only 
available  measure.  This  may  enhance  the  patient's  comfort  by  reliev- 
ing pruritus  ;  and  it  ensures  against  a  possible  mistake  in  diagnosis. 


ANATOMY   AND   ABNORMALITIES 


>6\ 


THE  PANCREAS 

Anatomy.— Tli<  pancreas  lies  in  the  epigastric  and  left  hypo- 
chondriac regions,  crossing  the  posterior  abdominal  wall  at  the  Level 
of  the  tirst  Lumbar  vertebra,  its  head  nestling  in  the  duodena]  hollow 
opposite  the  2nd  and  3rd  Lumbar  vertebrae,  and  its  tail  abutting 
on  the  Bpleen  (Fig.  535).  The  greater  part  lies  behind  the  stomach, 
the  Lesser  sac  forming  its  mosl  important  anterior  relation.    The  main 


Fig.  535. — Diagram  showing  the  relations  of  the  pancreas. 

(/•'>-('■  "«•,"  Dec.,  1908,  by  permission  qfDr.  W.  J.  Mayo.) 

duct  (Wirsung's)  opens  into  the  second  part  of  the  duodenum,  3  or  i  in. 
from  the  pylorus,  either  directly  or  through  the  ampulla  of  Vater. 

The  pancreas  is  a  compound  tubular  gland,  resembling  the  parotid, 
but  more  loosely  arranged  and  possessing  interacinous  islands  of  small 
polygonal  cells  known  as  the  islands  of  Langerhans. 

Abnormalities. — The  head  of  the  pancreas  may  completely 
surround  the  duodenum.  An  accessory  pancreas,  varying  in  size 
from  a  hempseed  to  a  bean,  may  lie  in  the  wall  of  the  stomach,  duo- 
denum, jejunum,  or  ileum,  and  has  been  found  at  the  apex  of  a 
gastri'  -unal  diverticulum.      Rarely  the  pancreas  is  abnormally 

movable,  and  has  been  found  in  both  diaphragmatic  and  umbilical 
hernias. 


764  THE   PANCREAS 

INJURIES 

Though  more  rarely  injured  than  the  other  viscera,  the  pancreas  suffers 
slight  traumatisms  not  infrequently.  The  injury  may  be  penetrating,  or, 
much  oftener,  subcutaneous,  and,  though  commonly  confined  to  the  viscus. 
may  be  associated  -with  lesions  elsewhere.  There  may  result  extensive  and 
perhaps  fatal  haemorrhage,  or  escape  of  juice  with  retroperitoneal  inflamma- 
tion, or  acute  pancreatitis  due  to  bruising.  In  slighter  injuries  the  peritoneum 
covering  the  pancreas  is  often  torn,  and  blood  and  pancreatic  juice  escape 
into  the  lesser  sac,  leading  to  the  development  of  an  inflammatory  effusion 
or  pseudo-cyst  (see  p.  771)  and  the  production  of  fat  necrosis. 

Clinical  features. — The  symptoms  vary  with  the  severity  of  the 
trauma.  In  some  cases  there  is  profound  shock  or  haemorrhage  without 
localizing  signs  other  than  the  site  of  the  injury.  In  others,  shock  is  less 
severe,  and  is  accompanied  by  pain,  vomiting,  tenderness  and  rigidity  of  the 
upper  abdomen,  and  the  rapid  accumulation  of  free  fluid ;  in  such  a  case. 
subsidence  of  symptoms  and  resolution  may  occur,  or  the  development  of 
local  peritonitis  or  of  pancreatitis  may  be  indicated  by  increasing  symptoms 
and  a  rising  temperature  and  pulse-rate.  Permanent  recovery  may  ensue 
or  temporary  amelioration  be  followed  by  signs  of  an  inflammatory  effusion 
into  the  lesser  sac.  Glycosuria  rarely  occurs,  but  when  present  is  of  valuable 
diagnostic  significance. 

Treatment  must  at  first  be  expectant,  unless  there  are  evidences 
of  severe  internal  haemorrhage.  If  the  symptoms  steadily  become  accentuated, 
while  the  tenderness  and  rigidity  persist  or  a  mass  develops,  operative  inter- 
ference is  necessary.  The  pancreas  can  best  be  exposed  by  tearing  through 
either  the  gastro-hepatic  omentum  or  the  gastro-colic  omentum.  The  object 
of  the  operation  is  (1)  to  stop  haemorrhage,  (2)  to  prevent  leakage,  and  (3) 
to  provide  drainage. 

If  the  pancreas  is  found  torn  it  may  be  possible  to  tie  bleeding  vessels, 
and  then  to  suture  the  laceration — in  this  way  a  pancreas  completely  torn 
in  two  has  been  repaired.  Bleeding  having  been  stanched  and  an)'  associated 
injury  treated,  all  clots  must  be  removed  and  the  lesser  sac  either  irrigated 
or  thoroughly  mopped  out.  A  large  rubber  tube  must  be  inserted  and  packed 
round  with  gauze  to  control  haemorrhage  and  to  soak  up  escaping  juice. 

In  dealing  with  penetrating  wounds,  associated  injuries,  especially  of  the 
stomach,  must  be  carefully  sought.  In  some  few  cases,  fluid  with  the  charac- 
teristics of  pancreatic  juice  has  been  removed  from  the  chest  in  convalescence. 

PANCREATITIS 

Etiology. — Experimental  injection  of  a  variety  of  substances 
into  the  duct  of  "Wirsung  produces  acute  inflammation  with  haemor- 
rhages, and  glycosuria,  and,  later,  abscesses  or  chronic  inflammation. 
In  man,  gall-stones  frequently  coexist  with  pancreatitis,  while  some- 
times possibly  stones  have  been  passed  after  causing  the  inflammation. 
When  endeavouring  to  correlate  these  facts,  Opie  found  that  in  62  per 
cent,  of  subjects  the  termination  of  the  bile-duct  was  so  arranged 
that  a  small  stone  lodged  there  would  dilate  the  ampulla  and  permit 
retrojection  of  bile  into  the  pancreatic  duct ;  this  retrojected  bile 
may  have  the  same  effect  in  producing  pancreatitis  as  the  various 
substances  used  experimentally. 


PunDO*     OF 

LfMP 
OPE.H 


Key  to  Plate  101 


Sloughing  of  the  pancreas,  the  result  cf  acute  inflammation  of  seven 
weeks'  duration.  The  blackened  slough  is  lying  completely  separated 
from  the  head,  the  only  part  of  the  gland  to  be  spared.  Gall-stones 
are  seen  in  the  pancreatic  portion  of  the  common  duct,  and  fat 
necrosis  is  well  shown.     The  parts  are  exposed  from  behind. 


Plate  101. 


PANCREATITIS  7C>? 

\  the  same  agents  may  cause  acute  or  chronic  pancreatitis,  ■• 
explanation  for  the  Incidence  of  the  two  classes  musi  I"-  ~ « n i -_r  1 1 1 . 
Flexner  concludes  thai  the  sudden  cetrojectiOn  "I  fresh,  unaltered  bile 
causes  acute  changes,  while  the  bile  thai  is  found  in  cases  of  chronic 
obstruction,  containing  a  diminished  amount  of  salts  and  an  excess  of 
colloid  material,  sets  up  chronic  changes.  Causal  agents  carried  by 
the  blood-stream,  such  as  alcohol  or  tuberculous  toxins,  are  more  likely 
to  give  rise  to  chronic  than  to  acute  mischief. 

Varieties  of  pancreatitis. — Pancreatitis  may  consist  (1)  in 
inflammation  of  the  d/ucts  :  ot  (2)  in  inflammation  of  the  parenchyma. 

"Fat  necrosis"  and  haemorrhage  are  two  Eeaturea  so  strikingly 
characteristic  of  pancreatitis  that  they  must  be  separately  discussed. 

Fat  necrosis  was  first  properly  described  by  Balser  in  1882. 
The  appearance  is  quite  characteristic  (Plate  101),  and  consists  in 
small  localized  whitish  or  yellowish  necrotic  blotches  scattered  over 
the  fat.  varying  in  size  from  a  pin's  head  to  areas  \  in.  or  more  in 
diameter.  The  process  is  most  marked  near  the  pancreas,  but  is  often 
widely  distributed  over  the  omentum  and  mesentery  and  may  some- 
times even  be  seen  in  the  preperitoneal  fat.  This  phenomenon  results 
from  splitting  up  of  the  fatty  molecule  into  its  fatty  acid  and  glycerine 
by  the  escaped  pancreatic  juice.  It  is  common  in  acute,  but  uncommon 
in  chronic  pancreatic  lesions. 

The  haemorrhage  may  either  show  itself  in  the  substance  of  the 
gland,  as  a  bloody  peritoneal  effusion,  or  as  a  general  tendency  to 
bleeding.  Haemorrhage  into  the  gland  may  take  the  form  of  a  massive 
bleeding — the  so-called  "  pancreatic  apoplexy,"  which  has  been  recorded 
in  vascular  and  blood  diseases,  sepsis,  and  poisoning,  usually  in  fat 
people.  Haemorrhagic  peritoneal  effusion  is  seen  in  acute  pancreatitis, 
and  when  associated  with  fat  necrosis  forms  a  striking  picture. 

The  general  tendency  to  bleeding  is  seen  in  the  chronic  varieties, 
with  or  without  jaundice.  In  these  cases,  remote  spontaneous  haemor- 
rhages may  occur  under  the  skin,  but,  of  course,  the  tendency  to 
bleeding  is  principally  observed  after  operations. 

Morbid  anatomy. — The  slighter  changes  in  the  pancreas  are 
not  visible  to  the  naked  eye.  This  is  especially  true  of  the  changes 
following  catarrhal  inflammation  of  the  ducts  and  of  those  in  chronic 
pancreatitis. 

In  acute  pancreatitis  the  pancreas  may  be  embedded  in  blood, 
or  may  be  but  a  little  larger  and,  in  the  early  stages,  firmer  than  normal. 
There  may  also  be  areas  of  softening  of  the  pancreatic  substance  with 
definite  evidence  of  gross  infection.  Later,  necrosis  of  considerable 
areas  of  the  gland  is  obvious,  and  may  involve  either  scattered  patches 
or,  more  commonly,  an  extensive  portion  of  the  body,  but  the  head  and 
extreme  end  of  the  tail  are  often  spared.     In  very  acute  cases    the 


766  THE   PANCREAS 

pancreas  may  become  a  disintegrating  mass  associated  with  retroperi- 
toneal cellulitis,  but,  when  time  permits,  the  parts  around  form  the 

walls  of  an  abscess  cavity  in  which  a  large  slough  may  lie  completely 
separated  from  the  rest  of  the  gland  (Plate  101).  Such  an  abscess 
may  burst  into  one  of  the  hollow  viscera,  or  even  externally,  and 
in  this  way  part  of  the  pancreas  may  be  discharged,  and  the  patient 
recover. 

In  all  cases  peritonitis  is  considerable,  most  marked  about  the 
pancreas,  and  sometimes  localized  in  the  lesser  sac  (inflammatory 
effusion  into  the  lesser  sac).  The  effusion  may  be  serous,  hemorrhagic, 
or  deeply  bile-stained. 

In  chronic  inflammation  few  changes  may  be  apparent  to  the 
naked  eye  ;  but  sometimes  the  whole  gland  is  a  little  enlarged  and 
uniformly  hard,  looking  like  a  "  waxen  cast  "  ;  or,  again,  the  head  only 
may  be  enlarged,  irregular,  and  knobby,  like  a  malighanl  tumour. 

Microscopically,  there  are  two  forms  of  chronic  pancreatitis — (1)  the 
interstitial  interlobular  variety,  in  which  the  normal  connective  tissue 
is  converted  into  a  dense  fibrous  stroma  compressing  and  gradually 
replacing  the  gland,  and  (2)  the  interacinous  variety,  in  which  the 
fibrous  tissue  separates  the  glandular  acini  and  even  sometimes  the 
separate  cells.  In  this  form  the  cell  islands  are  soon  involved  and 
diabetes  often  supervenes. 

Clinical  features.  Catarrhal  pancreatitis.  —  Catarrhal 
inflammation  probably  often  precedes  the  more  acute  processes  and 
may  arise  after  influenza,  or  as  a  complication  or  sequel  of  mumps,  and 
probably  is  the  active  feature  in  many  cases  of  so-called  catarrhal 
jaundice. 

Suppurative  catarrh  of  the  ducts  resembles  suppurative  cholangitis, 
with  which  it  is  usually  associated.  It  may  also  occur  with  pancreatic 
calculi.    The  treatment  is  external  drainage  via  the  common  bile-duct. 

Acute  pancreatitis  usually  occurs  about  middle  life,  the  period 
of  election  being  between  35  and  50,  though  it  has  occurred  in  a  child 
of  only  5,  and  in  a  man  of  75.  Males  are  affected  twice  as  often  as 
females.  Although  the  disease  may  attack  healthy  patients,  there 
is  frequently  a  history  of  antecedent  dyspepsia  and  of  seizures  of  pain 
in  the  upper  abdomen,  and  in  about  25  per  cent,  of  the  cases  the 
victims  are  stout  people  of  alcoholic  habits. 

The  onset  is  always  sudden,  and  usually  very  acute,  with  epigastric 
pain  so  severe  and  collapse  so  profound  that  perforation  of  the  stomach 
is  closely  simulated.  Epigastric  tenderness  and  muscular  rigidity  in 
the  supra-umbilical  zone  are  associated  with  violent  belching  and 
vomiting.  The  pulse  is  small  and  thready,  and  cyanosis  may  be 
marked.     Such  cases  may  end  fatally  within  twenty-four  hours. 

In  those  that  survive  the  early  collapse,  inflammatory  symptoms 


ACUTE    PANCREATITIS  767 

supervene ;    usually  the  pulse  now  becomes  accelerated,  but  H   may 
remain  sl"\\ . 

stipatioD  is  generally  obstinate,  bu1  there  may  be  diarrhoea  and 
even  melena.  Albuminuria  is  common;  glycosuria  is  rare,  but,  if 
found,  helps  to  confirm  the  diagnosis.  Slighl  jaundice  occurs  in  about 
one-fifth  of  1  hi 

Locally,  there  are  a1  firsl  greal  tenderness  and  rigidity  in  the  upper 
abdomen,  and  in  bom  twelve  t<>  twenty-four  hours  an  indefinite  mass 
may  be  fell  in  the  epigastrium  or  sometimes  in  the  left  lumbar  region. 
-till  the  >i>_rns  of  epigastric  or  diffuse  peritonitis  with  fluid  or  <>l 
retroperitoneal  cellulitis  may  be  superadded:  or  evidence  of  inflam- 
matory effusion  into  the  lesser  sac  may  indicate  a  tendency  to  localisa- 
tion and  subsequent  recovery. 

In  Borne  cases,  after  an  acute  ousel  the  symptoms  may  apparently 
disappear  for  a  time,  l>ut  the  pulse-rate  remains  fast,  and  a  mass  gradu- 
ally develops  in  the  pancreatic  region:  this  is  followed  by  localized 
suppuration  or  sloughing  of  the  gland  (Plate  101).  In  others,  ultimate 
recovery  after  a  prolonged  illness  may  follow  rupture  of  an  ab 
into  the  bowel,  or  temporary  improvement  may  end  in  late  death 
from  pancreatic  insufficiency.  In  cases  of  another  class,  changes  are 
seen  similar  to  those  of  acute  pancreatitis,  but  of  a  milder  char; 
This  form  may  only  be  revealed  during  operations  for  cholelithiasis, 
and,  though  recovery  often  results  from  removal  of  the  calculi  and 
drainage,  is  of  grave  prognosis. 

Haemorrhage  from  neighbouring  vessels  is  especially  liable  to  occur 
in  acute  pancreatitis. 

Diagnosis  of  acute  pancreatitis. — Most  of  the 
have  been  mistaken  for  acute  intestinal  obstruction,  visceral  perforation, 
or  gall-stones.  The  most  important  features  are  the  agonizing  pain, 
often  unrelieved  by  morphia,  the  tendency  to  cyanosis,  and  the  very 
marked  epigastric  tenderness,  soon  followed  by  the  development  of  a 
mass.  These  symptoms,  with  evidence  of  epigastric  peritonitis  and  a 
subsequent  inflammatory  swelling  posteriorly,  particularly  if  in  the 
left  lumbar  region  (Korte),  are  suggestive  of  acute  pancreatitis.  The 
discovery  of  fat  necrosis  on  opening  the  abdomen  is  strongly  con- 
firmatory. The  Cammidge  test  is  unreliable  in  the  early  stages  of  acute 
pancreatitis.  A  diagnosis  of  gall-stone  disease  is  often  correct,  but 
a  more  serious  pancreatitis  may  accompany  it. 

The  prognosis  in  acute  pancreatitis  is  always  very  grave, 
the  mortality  being  probably  75  per  cent. 

Treatment  of  acute  pancreatitis. — Whenever  acute  pan- 
creatitis is  suspected  an  operation  is  demanded  :  (1)  to  remove  the 
cause,  which  will  usually  mean  removal  of  gall-stones  and  drainage  of 
the  bile  passages  ;   (2)  to  relieve  tension  about  the  pancreas  by  dividing 


THE   PANCREAS 

its  peritoneal  covering;  (3)  to  remove  fluid  from  the  peritoneum; 
and  (1)  to  provide  drainage.  Korte,  however,  holds  that  under  no 
consideration  should  the  gall-bladder  be  incised  and  drained  at  the 
primary  operation  while  the  patient  is  collapsed. 

The  gland  is  best  exposed  by  a  free  median  incision.  Probably,  most 
benefit  follows  tree  external  bile  drainage,  and  many  cases  are  cured 
by  this  alone.  The  pancreas  should  be  exposed  by  tearing  through  the 
small  omentum,  and  then  through  the  overlying  peritoneum.  Any 
accumulation  of  fluid  in  the  lesser  sac  will  thus  be  evacuated  and  an 
escape  provided  for  retroperitoneal  extravasation.  Incision  of  the 
substance  of  the  pancreas  itself  is  of  doubtful  value  ;  if  it  be  done,  a 
dissector  should  be  employed  for  the  purpose,  owing  to  the  risk  of 
severe  haemorrhage.  If  the  general  peritoneal  cavity  contain  much 
fluid,  it  should  be  emptied  and  drained.  When  there  is  a  definite 
localized  mass  the  surgeon  may  find  a  considerable  retroperitoneal 
collection,  which  may  be  drained  from  the  front.  When  the  case  is 
of  longer  duration  and  the  symptoms  indicate  sloughing  of  a  consider- 
able part  of  the  gland,  the  sloughs  must  be  sought  and  removed.  *Holes 
into  the  bowel  for  natural  evacuation  must  not  be  overlooked. 

Relapses  after  operations  for  acute  pancreatitis. — The  majority  of 
cases  that  survive  operations  for  acute  pancreatitis  appear  to  be  com- 
pletely cured,  though  a  proportion  develop  chronic  pancreatitis  or 
diabetes,  so  that  the  prognosis  after  operation  must  be  uncertain. 
Recurring  attacks  of  pain  are  probably  due  to  overlooked  gall-stones 
or  to  concomitant  duodenal  ulcer.  Sometimes  a  cyst  develops  as  a 
late  result,  or  slight  recurrence  may  follow  insufficiently  prolonged 
drainage. 

Chronic  Pancreatitis 

This  group  includes  all  cases  that  come  on  gradually  and  that  are 
attended  by  an  increase  of  fibrous  tissue.  The  etiology,  pathology,  and 
morbid  anatomy  have  been  already  described.  The  disease  is  rarely 
primary.  but  once  initiated  it  tends  to  increase  progressively,  and  to 
end  in  death. 

Changes  in  the  faeces.— (l)  The  stools  are  unusually  bulky,  soft, 
liglit-coli  iiued.  and  offensive,  while  there  may  be  a  spurious  diarrhoea  ;  (2)  there 
may  be  an  abnormal  amount  of  fat  (steatorrhcea) ;  (3)  sometimes  there  may 
be  faulty  digestion  of  meaty  food,  as  shown  by  the  discovery  of  undigested 
muscle  fibres  (azotorrhoea). 

Changes  in  the  urine — (1)  Glycosuria  is  rare  and  unreliable" as 
a  diagnostic  symptom  ;  (2)  alterations  may  be  detected  by  the  Cammidge 
reaction,  which  depends  on  the  fact  that  in  inflammatory  lesions  of  the 
pancreas  the  kidneys  excrete  a  substance  with  a  glyco-nucleo-proteid  content 
which  on  hydrolysis  yields  a  body  giving  the  reactions  of  a  pentose.1     This 

1  For  the  successful  performance  of  this  test  an  absolutely  reliable  chemist 
is  necessary,  as  all  the  manipulations  must  he  conducted  with  extreme  care. 


CHRONIC    PANCRE  Ml  I  IS 

reaction  is  only  a  [ink  in  the  ohain  of  evidence.    Some  reject  it  as  raluelesf 
and  misleading  in  diagnosing  pancreatitis.     Bui  a  typical  positive  n 
with  a  negative  control  is  Btrongly  suggestive  of  inflammatory  <  1  i  i 
■ 
Moynihan  Bums  up  thus:  "It'  azotorrhcea  and  steatorrhcea   are  Bimul- 
baneously  present,  the  evidence  in  favour  of  pancreatic  di  trong; 

if  also  the  pancreatic  action  is  present,  the  evidence  is  conclusive." 

Clinical  features.     The  cases  vary  verj    much  in  their  o 
and  may  usually  be  divided  into  the  following  groups: — 

1.  Those  in  which  atti  cks  of  pain  are  the  main  feature. 
•_'.  Those  in  which  the  firs!  definite  symptom  is  jaundice. 
3.  Those  with  general  failure  of  health  and  possibly  glycos 
1.  Cases  accidentally  discovered  at  operation,  in  which  the  symp- 
toms of  gall-stones  have  masked  those  of  the  pancreal 

In  the    first  group  the    condition  probably  begins  as  a  suba 
infection,  which  quietens  down  as  it  becomes  chronic.     The  attacks 
of  pain  may  he  due  to  little  outbursts  of  inflammation  or  to  tie 
stones,  the  original  cause.     In  these  cases  there  are  often  attacks  of 
shivering,   and  in  the   later   stage  there   are   apt   to   be  the  general 
symptoms  mentioned  in  the  third  group. 

The  second  group  includes  the  cases  in  which  the  condition  is  most 
commonly  mistaken  for  cancer.  Jaundice  may  gradually  deepen  with- 
out intermission,  and  the  patient  rapidly  waste.  If,  in  these  circum- 
stances, the  gall-bladder  be  distended,  cancer  is  closely  simulated. 

In  the  third  group  there  is  extreme  weakness  and  emaciation,  with 
loss  of  appetite  and  loathing  of  food.     The  skin  assumes  an  ei 
hue,  there  are  alterations  in  the  urine  and  faeces,  and  there  may  be 
diabetes. 

Many  cases,  undoubtedly,  fall  into  the  fourth  group,  and  are  dis- 
covered during  operations.  But  the  surgeon  must  not  be  led  into 
diagnosing  chronic  pancreatitis  from  undue  hardness  of  the  gland 
without  the  confirmatory  evidence  afforded  by  an  examination  of  the 
faeces  and  urine. 

Physical  signs. — In  any  of  these  groups  an  enlargement  of 
the  pancreas  may  be  felt,  the  gland  being  swollen  and  tender.  The 
enlargement  varies  from  time  to  time,  and  may  even  vanish  and 
reappear.  There  may  be  no  tumour,  but  tenderness  in  the  epigastrium 
or  just  above  and  to  the  right  of  the  umbilicus.  In  cases  with  jaundice 
the  gall-bladder  is  usually  felt  to  be  distended. 

Prognosis.  —  Chronic  pancreatitis  is  rarely  a  direct  cause  of 
death,  but  often  leads  to  fatal  diabetes. 

Treatment. — The  presence  of  a  definite  mass  with  or  without 
jaundice  indicates  the  necessity  for  operation.  Such  a  mass  may  be 
malignant  or  inflammaory  ;  if  the  latter,  it  may  disappear  after  mere 
exploration,   after  drainage  of    a   retroperitoneal  collection,   or  after 


77o  THE    PANCREAS 

cholecystenterostomy.  This  latter  operation  is  desirable,  it  possible, 
and  may  even  sometimes  prove  of  benefit  in  malignant  disease.  If  a 
satisfactory  anastomosis  be  found  very  difficult,  external  drainage 
should  be  substituted.  When  painless  jaundice  is  the  only  symptom, 
operation  should  be  deferred  for  at  least  six  weeks  to  give  time  for 
spontaneous  clearance,  lest  the  jaundice  be  only  catarrhal.  If  there  be 
merely  attacks  of  pain  confidently  attributable  to  pancreatic  involve- 
ment, operation  is  necessary,  for  the  attacks  may  proceed  from 
gall-stones  or  pancreatic  calculi.  If  there  be  no  removable  gross 
lesion,  it  is  a  moot  point  whether  anything  further  than  simple 
laparotomy  can  be  of  service,  though  some  recommend  routine  chole- 
cystenterostomy. 

When  a  general  failure  of  health  or  glycosuria  can  be  traced  to  pan- 
creatic involvement,  without  an  acute  onset  or  without  any  enlarge- 
ment of  the  organ,  surgical  intervention  is  to  be  avoided. 

SYPHILIS    AND    TUBERCULOSIS 

Syphilis  rarely  affects  the  pancreas.  It  may  take  the  form  of  an 
indurative  pancreatitis  or  of  a  gumma.  Isolated  gummata  have  been  recorded 
sufficiently  often  to  justify  administration  of  iodide  and  mercury  in  any 
case  of  irremovable  pancreatic  tumour,  without  unequivocal  signs  of  cancer. 

Tuberculosis  is  equally  rare,  but  may  occur  in  the  miliary  form,  or 
as  an  isolated  tuberculoma. 

PANCREATIC    CYSTS 

Classification. — Cysts  of  the  pancreas  may  be  classified  as 
follows  : — 

1.  True  cysts. 

Acinous. — (i)  Retention  cysts  ;  (ii)  Cystadenomas,  (a)  multilocular, 

(b)  papillomatous,  (c)  congenital  cystic. 
Interacinous. — (i)  Lymphatic,  (ii)  Parasitic. 

2.  Pseudo-cysts. 

Intraperitoneal. — Inflammatory  effusions  into  lesser  sac,  (a)  the 
result  of  injury,   (6)  secondary  to  pancreatitis. 

Retroperitoneal. — The  result  of  (i)  old  haemorrhage  or  necrosis  of 
pancreas,  (ii)  breaking  down  of  a  new  growth. 

Donoghue  has  drawn  attention  to  certain  parapancreatic  cysts 
which  spring  from  the  neighbourhood  of  the  tail  and  probably  originate 
in  the  remains  of  the  Wolffian  body. 

Pathology. — Of  the  true  cysts,  those  due  to  retention  are 
the  commonest.  For  the  most  part,  they  have  been  observed  post 
mortem,  and  have  presented  no  symptoms  during  life.  Though  usually 
the  size  of  an  orange,  they  may  be  as  large  as  a  man's  head,  or  even 
attain  enormous  proportions  necessitating  surgical  interference.  The 
obstruction  is  in  most  cases  a  consequence  of  chronic  interstitial  pan- 
creatitis. 


PANCREATIC   CYSTS  77* 

The  cy8iadenoma8  are  still  more  care.  They  may  give  rise  bo  no 
Bymptoma  during  life,  and  only  be  discovered  al  necropsy,  as  in  the 
case  shown  in  Fig.  536,  or  one  or  more  of  (lie  loculi  may  attain  large 
size,  giving  rise  to  al]  the  Bigns  of  pancreatic  cysts. 

Sometimes  these  tumours  contain  papillomas,  while  in  other  cases 
their  structure  suggests  cystic  epithelioma  or  carcinoma. 

Congenital  cystic  disease  also  very  rarely  occurs,  and  is  associated 
with  the  .same  condition  in  other  organs. 

Interacinous  cysts. — Hydatids  bear  this  relation  to  the  gland,  but 
are  rare  in  the  pancreas. 

All  the  varieties  of  true  cyst  occur  most  commonly  in  the  tail, 
though  they  may  be  found  in  any  part  of  the  gland. 

Pseudo-cysts. — If  we  dismiss  the  cystic  conditions  due  to  the 
softening  and  breaking  down  of  malignant  new  growths,  there  are  two 
principal  conditions  to  be  discussed  under  this  head — (1)  the  retro- 
peritoneal collection  of  fluid  in  association  with  the  breaking  up  of  the 
pancreas  from  old  haemorrhage  or  inflammation  ;  (2)  inflammatory 
effusions  into  the  lesser  peritoneal  sac. 

Jordan  Lloyd  first  drew  attention  to  the  cases  which  follow'  on 
injury.  Laceration  of  the  pancreas  is  combined  with  tearing  of  the 
overlying  peritoneum,  so  that  there  is  an  escape  of  blood  and  pan- 
creatic juice  into  the  lesser  sac.  This  leads  to  an  inflammation,  which 
results  in  the  closing  of  the  foramen  of  Winslowr,  and  further  adds  to 
the  effusion  distending  the  lesser  sac.  Sometimes  even  gall-stones, 
bile,  and  pancreatic  fluid  have  been  found  in  this  situation. 

The  content  of  pancreatic  cysts  is  an  alkaline  albuminous 
fluid,  having  a  specific  gravity  of  1010  to  1020.  It  is  either  clear 
or  a  reddish-brown,  or  definitely  blood-stained,  and  usually,  though 
not  invariably,  contains  one  or  more  of  the  pancreatic  ferments. 

Secondary  changes. — In  some  cases  haemorrhage  occurs  into 
a  cyst,  either  from  injury  or  from  erosion  of  vessels,  and  may  later 
lead  to  the  suggestion  that  such  a  cyst  has  arisen  in  an  old  haemorrhage. 
Secondary  infection  may  take  place,  and  may  lead  to  acute  symptoms. 
Malignant  disease  may  also  arise. 

Anatomical  relations.— A  pancreatic  cyst  sufficiently  developed 
to  be  recognized  may  present  in  a  variety  of  situations :  (a)  above  the 
stomach,  between  it  and  the  liver;  (b)  behind  the  stomach;  (c)  below  the 
stomach,  between  it  and  the  transverse  colon ;  (d)  below  the  transverse 
colon;  (e)  behind  the  stomach  and  colon;  (/)  between  the  layers  of  the 
mesocolon.  The  relations  of  a  pancreatic  cyst  also  depend  on  whether  it 
springs  from  the  head,  the  body,  or  the  tail  of  the  gland. 

An  effusion  into  the  lesser  sac  of  the  peritoneum  (pseudo-cyst)  causes  a 
general  bulging  of  the  epigastric  and  left  hypochondriac  regions  with  pro- 
minence of  the  lower  part  of  the  chest  on  that  side  ;  as  it  increases,  the 
umbilical  and  left  renal  regions  may  be  similarly  invaded.     The  stomach  is 


PANCREATIC   CI  sis  773 

lifted  forwards  and  pushed  upwards,  while  the  <■« >l< >n  is  thrust  downwards 
and  forwards  against  the  bell}  wall.    On  the  left  the  swelling  impinges  on  1 
parietes  jus!   bekwi   the  costal  margin,  the  Bpleen  being  pushed  up  and  the 
Bplenio  flexure  down,  so  thai  in  this  situation  such  an  effusion  oan  easily  be 
reached  by  i  be  Burgeon. 

Clinical     features.     Cysts    are    generally    found     in    adults, 
though  they  may  occur  even  in  infants.    Whereas  true  cysts  comm<  - 
gradually,  and  are  often  discovered  accidentally,  pseudo-cysts  invari- 
ably follow  injury  or  Borne  acute  inflammatory  disturbance. 

In  tlic  true  cysts  the  symptoms  usually  depend  on  the  size  of  the 
tumour,  and  may  merely  be  those  of  epigastric  Inline"  or  distress,  or 
there  may  be  nausea  and  vomiting,  symptoms  of  intestinal  obstruction, 
or  jaundice  from  pressure  on  the  bile-ducts.  Pain,  when  present,  often 
heralds  secondary  changes.  As  a  rule,  there  are  no  characteristic  urinary 
changes.  The  cysts  feel  suit  and  cystic  when  large,  bul  firm  and  solid 
when  small. 

The  history  of  the  pseudo-cysts  that  arise  as  the  result  of  injury 
is  usually  that  of  a  blow  or  crush  of  the  upper  abdomen,  followed  by 
severe  pain,  with  Bigns  of  collapse,  and  with  tenderness  and  rigidity  ir. 
the  epigastrium.  These  symptoms  usually  subside  in  the  course  of  a 
day  or  two.  but  later  there  is  a  return  of  the  pain,  accompanied  by 
a  sense  of  fullness  in  the  upper  abdomen  ;  here  a  swelling  soon  becomes 
obvious,  and  often  so  rapidly  increases  in  size  as  to  cause  dyspnoea 
within  a  very  few  days.  The  history  is  not  always  so  rapid,  and  there 
may  be  an  interval  of  a  week  or  even  some  months  before  a  recurrence 
of  pain  and  the  appearance  of  a  swelling  reveal  the  nature  of  the  case. 

Diagnosis. — The  diagnosis  is  usually  a  question  of  the  differen- 
tiation of  a  cystic  tumour  in  the  upper  abdomen,  because,  as  a  rule, 
evidence  of  interference  with  the  pancreatic  function  is  absent ;  if 
present,  however,  urinary  or  faecal  changes  may  be  of  great  con- 
firmatory value. 

Prognosis. — In  true  cysts  of  the  pancreas  a  spontaneous  cure 
never  occurs.  The  inflammatory  effusions  into  the  lesser  sac  may 
disappear  without  treatment,  but  generally  tend  to  get  rapidly  worse. 

Treatment. — Puncture  or  aspiration  should  never  be  employed, 
as  it  involves  a  grave  risk  of  sepsis  or  haemorrhage,  without  any  com- 
pensating advantage.  Complete  extirpation,  though  an  ideal  method, 
can  seldom  be  satisfactorily  carried  out. 

Drainage  is  the  treatment  most  generally  applicable  and  satis- 
factory. The  parietal  abdominal  incision  should  be  made  over  the 
most  accessible  part  of  the  cyst,  usually  in  the  middle  line  above  the 
umbilicus.  After  protecting  the  general  peritoneal  cavity  by  gauze 
packing  or  by  Brightly  withdrawing  the  cyst,  if  possible,  from  the 
abdomen,  the  surgeon  evacuates  the  cyst  and  carefully  examines  its 


774  THE    PANCREAS 

interior  for  secondary  cysts  or  calculi.  If  the  cyst  can  be  brought 
to  the  surface,  he  then  marsupializes  it  by  stitching  the  edges  of  the 
opening  to  the  abdominal  wall ;  if  not,  he  must  fix  a  dressed  tube 
into  the  cyst  by  means  of  a  purse-string  suture,  or,  failing  this,  must 
rely  on  careful  packing  to  prevent  leakage.  The  discharge  will  pro- 
bably be  scanty  at  first,  but  it  soon  becomes  abundant  and  proteolytic. 
In  an  ordinary  case  the  track  will  close  in  about  four  to  eight  weeks. 
Sometimes  lumbar  drainage  has  been  found  necessary,  but  as  a 
primary  operation  this  can  only  be  necessary  in  deep-se  Ued  cysts. 

NEW    GROWTHS 

With  the  exception  of  cysts,  all  tumours  of  the  pancreas  are  com- 
paratively rare.  Of  the  simple  tumours,  adenomas  and  cystadenomas 
have  been  most  often  observed.     Such  tumours  have  been  successfully 

removed. 

Carcinoma 

May  be  primary  or  secondary.  Primary  cancer  may  be  masked  by 
the  resultant  enlargement  of  the  liver.  The  growth  may  commence 
in  any  part,  but  is  commonest  in  the  head,  where  it  may  form 
a  hard,  nodular,  rounded  mass  the  size  of  an  orange,  or  it  may  be 
diffuse.  A  striking  feature  is  the  enormous  dilatation  of  the  gall- 
bladder which  occurs  when  the  bile-duct  is  compressed  (Plate  102). 
Very  often  a  cancer  involving  the  head  of  the  pancreas  has  had  its 
origin  in  the  glands,  and  not  in  the  pancreas  itself. 

Clinical  features. — The  disease  is  more  common  in  males,  and 
usually  occurs  between  the  ages  of  40  and  60.  The  cases  can  be  sepa- 
rated into  three  groups,  according  to  whether  the  bile-duct,  the  portal 
vein,  or  the  duodenum  is  most  involved.  In  the  first  group,  jaundice 
is  the  most  prominent  symptom — it  comes  on  gradually,  and  stealthily 
deepens  until  the  patient  is  of  an  olive-green  colour,  with  a  marked 
tendency  to  haemorrhage  and  an  intolerable  itching  ;  in  the  second 
group,  ascites  is  the  prominent  feature  ;  and  in  the  third,  gastric  symp- 
toms, depending  on  obstruction  of  the  duodenum ;  but,  in  any  case, 
jaundice  is  almost  certain  to  appear  at  some  stage  of  the  illness.  Pain 
may  be  present,  usually  above  the  umbilicus  and  through  to  the  back. 
Unaltered  fat  or  undigested  muscle  fibres  may  be  found  in  the  faeces. 
Glycosuria  is  only  present  when  the  whole  gland  is  involved,  or  when 
there  is  chronic  pancreatitis.  The  absence  of  urobilin  points  to 
cancer. 

Diagnosis. — In  gall-stones  there  is  nearly  always  a  history  of 
previous  attacks,  an  onset  attended  with  pain,  intermissions  in  the 
jaundice,  and  an  absence  of  palpable  tumour  or  enlarged  gall-bladder. 
(Fig.  519.)  Chronic  pancreatitis  may  exactly  simulate  cancer,  but  there 
is  usually  a  history  of  coincident  gall-stone  attacks.     The  jaundice  is 


Enormous  distension  of  the  gall-bladder,  secondary  to  malignant  disease 
of  the  head  of  the  pancreas. 


Plate  102. 


PANCREATIC    LITHIASIS     FISTULA  775 

no!  so  deep,  nor  is  \v;isiin<_f  so  marked,    while  characteristic  chan 
are  more  likely  to  be  found  in  the  urine  and  the  duration  is  longer. 

Prognosis.  -Tin-  disease  seldom  lasts  longer  than  six   to  tv 
months,  and  may  end  fatally  in  a  much  shorter  period. 

Treatment.  New  growths  limited  to  the  tail,  and  even  some  in 
i  be  body  of  I  be  gland,  have  been  successfully  removed.    Tumours  arif 

in  thf   head   of  tin"  gland   bave  occasionally  I □  shelled   out,   but 

Desjardins,  in  1907,  worked  ou1  experimentally  an  operation  for  com- 
plete excision  of  this  pari  of  the  gland  which  gives  promise  of  success. 
As  a  palliative  measure,  cholecystenterostomy  is  sometimes  available, 
and  may  be  worth  while  merely  to  relieve  the  intense  itching; 

If  the  signs  of  cancer  are  not  unequivocal  this  operation  should 
certainly  be  performed,  for  it  may  cure  a  doubtful  case. 

PANCREATIC   LITHIASIS 

Pancreatic  calculi  are  very  rare.  Though  usually  only  discovered  after 
death,  they  have  been  found  during  life,  either  in  the  faeces  or  in  the  course 
of  operation,  and  have  occasionally  been  diagnosed  and  deliberately  removed. 

The  calculi  are  long  and  ovah  or  resemble  coral,  and  vary  in  size  from 
material  like  sand  to  masses  as  big  as  a  hazel-nut.  Chemically,  they  are 
composed  of  carbonate  and  phosphate  of  lime  or  magnesia,  and  arc.  therefore, 
opaque  to  the  Rontgen  rays. 

Symptoms  may  be  entirely  absent  ;  and.  in  any  case,  none  can  be 
claimed  as  pathognomonic.  In  some  cases,  after  attacks  of  pain  like  gall- 
stone colic,  but  most  intense  under  the  left  costal  arch  and  in  the  left 
shoulder,  pancreatic  calculi  have  been  found  in  the  stools.  There  may  be 
symptoms  of  a  concomitant  pancreatitis,  and  a  positive  pancreatic  reaction 
has  often  been  obtained. 

Treatment. — If  diagnosed  by  the  X-rays,  the  location  of  the  calculi 
will  be  indicated.  Those  in  the  main  duct  may  be  removed  through  the 
duodenum  by  enlarging  the  papilla,  otherwise  the  pancreas  may  be  directly 
incised. 

PANCREATIC    FISTULA 

This  is  usually  a  sequel  to  some  operation  on  the  pancreas,  either 
for  injury,  inflammation,  or  the  treatment  of  a  cyst. 

The  constant  escape  of  secretion  leads  to  digestion  of  the  surround- 
ing skin,  which  soon  becomes  extensively  excoriated.  Such  a  fistula 
may  be  very  chronic,  and  may  even  resist  treatment  for  years.  Beyond 
the  local  inconvenience  and  the  loss  of  secretion,  the  condition  may 
be  a  source  of  septic  absorption  and  of  subsecment  lardaceous  disease. 
The  amount  of  discharge  varies  with  the  character  of  the  food  taken, 
in  response  to  the  physiological  excitation  of  the  organ. 

Treatment. — It  is  first  necessary  to  see  that  there  is  no  cause 
likely  to  keep  the  fistula  active,  such  as  a  mass  of  sloughing  pancreas. 
Drainage  must  not  be  hampered  by  too  small  an  opening  in  the  parietes ; 
it  must  be  allowed  to  be  free,  and  the  surrounding  skin  protected  by 


THE    PANCREAS 

bland  dusting  powders  and  ointments.    To  lessen  the  discharge,  W'ohl- 

gemuth   recommends   a   carbohydiate-free   diet:    with    frequent  small 
-  of  bicarbonate  of  soda.     Fats  should  be  given  plenteously. 
To  encourage  closure  of  the  fistula,  Beck's  bismuth  paste  may  be 
!.  or,  as  a  last  resource,  thorough  cauterization  may  be  employed. 

Excision  of  the  track  is  no1   advisable.     Sometimes  when  the  fistula 

closes  the  cyst  re-forms. 

BIBLIOGRAPHY 

Bland-Sutton,  Sir  John.   Gall-Stones  and  Diseases  of  th    Bile-Duds.     1910 

Desjardins,  Ju<-.  ,h   Chir.,  L907,  \.\w.  945. 

Drummond  and  Morison.  "  A  Case  of  Ascites  due  to  Cirrhosis  of  the  Liver,  cured 
by  Operation,"  Brit.  Med.  Journ.,Sept.  19th,  i 

Halsted,  William  S.,  "  Retrojection  of  Bil<-  into  the  Pancreas  a  Cause  of  Acute 
Bsemorrhagi  Pancreatitis";  and  Eugene  L.  Cpie.  "The  etiology  of  Acute 
Ssemorrhagic   Pancreatitis,"  Johns  Hopkins  Hosp.  BuU.,  Nos.  121-3. 

Handley,  W.  Sampson,  "  Eunterian  Lectures  on  Surgery  of  Lymphatic  System," 
Brit.  Med.  Journ.,  April  L6th,  L910. 

Kehr,  Prof.  H.,  "Injuries  and  Diseases  of  the  Liver  and  Biliary  Passages,"  Berg- 
mann's  SysU  m  of  Practical  Surgt  ry,  \  \  1.  iv. 

Kbrte,  W..  "  Surgii  al  Treatment  of  Acute  Pancreatitis,"  A  nn.  of  Sing.,  Jan.,  1912. 

Lejars,  Felix,  trans,  by  W.  s.  Dickie,   Urgent  8urgery. 

Maccarty,  William  Carpenter.  "  Pathology  of  the  Gall-Bladder  and  Eome  Associated 
Lesions,"  Ann.  of  Surg.,  .May.  1910. 

Mayo,  William  J.,  "A  Review  of  Fifteen  Hundred  Operations  upon  tbe  Gall- 
Bladder  and  Bile  Passages,  with  especial  reference  to  the  .Mortality,"  Ann. 
of  Surg.,  Aug.,  L906. 

Mayo,  William  J.,  "  Surgical  Treatment  of  Pancreatitis.'  n.,  and  Olttd., 

Dec.,  1908. 

Morison,  R.,  Brit.  Med.  Journ.,  Nov.  3rd,  1894. 

Moynihan,  Sir  Berkeley,  Gall-Stones  and  their  Surgical  JVi  1905. 

Robson  (Mayo)  ami  Cammidge,   Th   Pancreas,  its  Surg  H07. 

Rolleston,  H.  D.,  Diseases  of  '  all-Bladder,  and  Bih  -Ducts.    W 


THE  UPPER  AND  LOWER  URINARY  TRACT 
By  J.W.THOMSON  WALKER,  M.B.Ed.  F.R.C.S.Eng, 

THE    KIDNEY 

Anatomy  of  the  kidney.  The  kidney  extends  obliquely  Iron. 
the  level  of  the  middle  of  the  11th  dorsal  vertebra  to  that  of  the 
transverse  process  of  the  3rd  Lumbar  vertebra.  Behind  it  lie  the 
diaphragm,  and  the  anterior  layer  of  transversalis  aponeurosis,  which 
separates  it  from  the  quadratus  lumborum  muscle,  the  costo-vertebral 
ligament,  and,  at  the  lower  pole,  the  psoas.  The  pleura  is  in  relation 
with  the  kidney  between  the  diaphragmatic  origin  from  the  external 
arcuate  ligament  and  the  12th  rib.  The  anterior  relations  are  shown 
in  the  accompanying  diagram.     (Fig.  537.) 

The  kidney  lies  embedded  in  a  fatty  capsule  contained  within  the  fascia 
propria  or  perirenal  fascia.  The  perirenal  fascia  appears  between  the 
transversalis  fascia  and  peritoneum,  and  divides  at  the  outer  renal  border  into 
an  anterior  layer  which  crosses  in  front  of  the  kidney  and  greal  vessels, 
and  a  stronger  posterior  layer,  the  fascia  of  Zuckerkandl,  which,  after  supplying 
a  fine  covering  to  the  renal  vessels,  becomes  attached  to  the  vertebral  bodies. 
Above,  the  layers,  after  enclosing  the  suprarenal,  become  attached  to  the 
diaphragm  ;  below,  the  anterior  layer  lines  the  peritoneum,  while  the  posterior 
layer  is  gradually  lost  in  the  extraperitoneal  fat.  The  perirenal  fascia  thus 
forms  an  envelope  open  on  its  internal  and  inferior  aspects.  The  true  renal 
capsule  closely  invests  the  organ  and  enters  the  hilum,  but  is  easily  stripped 
from  the  surface. 

The  renal  pelvis  is  the  trumpet-shaped  upper  expansion  of  the  ureter 
which  enters  the  sinus  of  the  kidney.  It  usually  presents  two  primary  divi- 
sion-, each  divided  into  calyces,  and  on  the  average  can  hold  3J  drachms, 
though  distension  with  more  than  2  drachms  causes  pain. 

The  renal  artery  divides  at  the  hilum;  two  or  three  branches  pass 
in  front  of  and  one  behind  the  pelvis.  One  of  the  anterior  branches  passes 
to  the  upper  pole,  sometimes  without  entering  the  hilum.  The  arterial 
supply  is  divided  into  an  anterior  and  a  posterior  system,  independent  of 
each  other.  The  least  vascular  line,  or  exsanguine  line  of  Hyrtl,  runs  parallel 
to  and  a  little  behind  the  convex  border,  and  separates  the  anterior  and 
posterior  arterial  systems. 

An  additional  renal  artery  is  present  in  about  20  per  cent,  of  bodies, 
more  commonly  on  the  left  side. 

777 


778 


THE   KIDNEY 


Lymphatics  of  the  kidney.— The  glands  earliest  affected  in  renal 
malignant  disease  are  those  at  the  liilum,  those  along  the  vena  cava,  and 
those  between  the  aorta  and  the  spermatic  vein.  The  lymphatics  from  the 
hilum  to  the  glands,  along  the  great  vessels,  do  not  anastomose  with  neigh- 
bouring plexuses. 

Attachments  Of  the  kidney. — The  following  structures,  which  pre- 
vent displacement,  but  allow  free  movement  (3  to  5  cm.)  with  respiration, 
combine  to  support  the  kidney:  (1)  The  renal  vessels;  (2)  the  peritoneum; 
(3)  the  attachment  of  the  retroperitoneal  surfaces  of  the  duodenum,  colon, 
and  pancreas ;  (4)  the  adhesions  to  the  suprarenal  capsule ;  (5)  the  perirenal 


Fig.  537. — To    illustrate    the    anterior    relation    of    the  kidneys 
(diagrammatic). 

i  and  2,  Peritoneum-covered  surface  of  right  kidney  in  apposition,  respectively,  with  liver 
and  small  intestine  ;  3  to  5,  peritoneum-covered  surface-  of  left  kidney  in  af  position,  respec- 
tively with  stomach,  spleen,  and  small  intestine  ;  6,  duodenum  ;  7.  duodeno-jejunal  junction  ; 
8,  hepatic  flexure  of  colon  ;  9,  ascending  colon  ;  10,  splenic  flexure  ;  n,  descending  colon  ; 
12,  attachment  of  transverse  mesocolon;  13,  suprarenals;  14,  gastric  surface  of  spleen: 
35,  splenic  vessels;  36,  pancreas;  17,  inferior  vena  cava  ;  18,  aorta  ;  19,  superior  mesenteric 
arteiy;  20,  superior  mesenteric  vein ;  21,  ureters.  __ 


fascia  and  the  network  of  fine  fibres  which  pass  to  it  from  the  renal  capsule ; 
(6)  the  perirenal  fat ;  (7)  the  fascia  of  Toldt,  which  connects  the  perirenal 
fascia  on  the  right  side  with  the  hepatic  flexure  and  the  duodenum,  and  on 
the  left  with  the  splenic  flexure;  and  (8)  the  intra-abdominal  pressure. 

THE   EENAL   FUNCTION 

The  function  of  the  kidneys  in  disease  may  be  estimated  by  observing 
symptoms  of  renal  failure,  by  the  examination  of  the  urine,  and  by  certain 
tests. 

1.  Signs  and  symptoms  of  renal  failure Thirst  is  the  most 

frequent  symptom,  and  is  more  severe  at  night.  The  tongue  is  dry,  at  first 
along  the  centre,  and  later  over  the  whole  surface.  It  becomes  red,  glazed, 
and  cracked.  In  the  later  stages  of  urinary  septicaemia  it  is  covered  with  a 
dry  brown  fur  ("parrot  tongue").    There  are  loss  of  appetite  and  inability  to 


TESTS   OF   THE    RENAL    FUNCTION  779 

take  .solid  1m.hI.  Nausea  ,'111(1  vomiting  arc  late  symptoms.  There  is  frontal 
headache  The  Bkin  is  drj  and  harsh,  and  the  face  lias  a  peculiar  yellow 
earthy  look  in  the  late  stages.  Emaciation  is  often  present.  Hiccup  and 
drowsiness  are  grave  symptoms.    The  temperature  is  subnormal  in  all  aseptic 

■  uses  and  in  chronic  septic   pyelonephritis. 

2.  Examination   of    the    urine.     A    persistently    lorn     specific 
rity  (1010  or  less)  is  a  grave  symptom,  and  continuous  reduction  in  the 

urea  output  shows  a  seriously  impaired  renal  function.  In  sonic  cases  poly- 
uria, in  others  oliguria  or  anuria,  may  be  evidence  of  renal  inadequacy. 

:5.  Special  tests  of  the  renal  function,  (o)  Cryoscopy. 
— Cryoscopy  consists  in  determining  the  freezing-poinl  (A)  of  the  mine  or 
of  t he  blood  and  urine.  By  this  means  the  amounl  of  solids  held  in  solution 
by  each  fluid  is  ascertained,  and  an  estimate  of  the  work  performed  by  the 
kidney  can  be  made.  The  A  of  the  urine  lies  between  — 1-30°  and  —  2*20°  C, 
and  of  the  blood  at  — 0'56°C.  There  are  many  fallacies  in  this  method,  and 
it  is  unsuitable  for  general  clinical  use. 

(b)  Methylene-blue  test. — If  15  minims  of  a  5  per  cent,  aqueous 
solution  of  methylene  blue  are  slowly  injected  into  the  gluteal  muscles, 
chrornogen  (transformed  into  blue  by  boiling  with  acetic  acid)  appears  in  the 
urine  in  from  fifteen  to  twenty  minutes,  and  blue  itself  is  detected  half  an 
hour  after  the  injection.  The  urine  rapidly  becomes  olive  green,  emerald 
green,  bluish-green,  prussian  blue,  and  finally  a  deep  blue  colour.  The  colour 
may  not,  however,  pass  beyond  emerald  green.  The  excretion  of  blue  is  at 
its  height  in  four  or  live  hours,  remains  stationary  for  several  hours,  and  then 
gradually  declines.  It  has  usually  disappeared  in  from  forty  to  sixty  hours. 
the  chrornogen  disappearing  some  hours  earlier.  In  pathological  conditions 
of  the  kidneys  the  appearance  of  the  blue  is  delayed,  the  excretion  prolonged, 
and  the  total  quantity  reduced. 

(c)  IndigO-carmine  solution  is  also  used.  An  intramuscular  injection 
of  4  c.c.  of  a  4  per  cent,  solution  of  indigo-carmine  is  given,  and  the  urine 
is  stained  in  twenty  minutes.  The  elimination  reaches  its  maximum  half  an 
hour  later,  and  should  be  complete  in  two  hours.  This  method  is  specially 
useful  for  ehromocystoscopy.  the  depth  of  staining  of  the  efflux  of  each  ureter 
being  observed  with  the  cystoscopy 

(d)  PhloHdzin  test. — If  a  subcutaneous  injection  of  10  mg.  of  phlo- 
ridzin  be  given,  sugar  can  be  detected  in  the  urine  in  fifteen  or  sometimes 
thirty  minutes.  The  glycosuria  is  at  its  height  from  three-quarters  of  an 
hour  to  an  hour  after  the  injection,  and  has  usually  ceased  in  two  to  two 
and  a  half  hours.  It  amounts  to  1  to  2  giro,  of  glucose.  Delay  in  the 
appearance  and  reduction  in  the  total  quantity  of  sugar  indicate  a  re- 
duced renal  function.  The  lowest  limit  of  nqrmal  glycosuria  lies  between 
50  eg.   and  1  grin.,  and  the  highest  between  2  and  2-50  grm. 

(e)  Phenol-SUlphone-phthalein  test.1— This  test  is  at  present 
under  trial.  Half  an  hour  previous  to  the  injection  the  patient  drinks  300  c.c. 
of  water.  A  subcutaneous  injection  of  1  c.c.  of  a  solution  containing  6  mg. 
of  phenol-sulphone-phthalein  is  given,  and  the  urine  collected  in  a  test-tube 
containing  a  drop  of  25  per  cent.  NaOH  solution.  The  commencement  of 
elimination  is  noted,  and  the  quantity  excreted  during  the  first  and  second 
hours  is  estimated  by  comparing  the  urine  with  a  standard  solution  in  a 
Dubosq's  colorimeter.  Elimination  should  commence  in  from  five  to  eleven 
minutes  ;  40-60  per  cent,  of  the  drug  should  be  excreted  in  the  first  hour. 
20-25  per  cent,  in  the  second  hour. 

1  Geraghty,  Trans.  Amcr.  Assoc  of  Genito-Urinary  Surgeons,  vol.  v.,   1910. 


780  THE   KIDNEY 

EXAMINATION    OF    THE    KIDNEYS    BY    INSPECTION, 
PALPATION,    AND    PEKCUSSION 

A  greatly  enlarged  kidney  forms  a  rounded,  unilateral,  abdominal  swell- 
ing a  little  above  the  level  of  the  umbilicus  and  more  prominent  in  the 
recumbent  posture.  There  is  fullness  in  the  flank,  but  no  projection  back- 
wards. Where  the  renal  pelvis  is  greatly  distended  with  fluid  a  vertical 
groove  may  be  seen  on  the  surface  of  the  swelling. 

On  palpation  a  renal  tumour  presents  rounded  borders,  without  any 
sharp  edges,  and  frequently  retains  a  reniform  shape.  It  projects  forwards 
into  the  abdomen,  and  backwards  into  the  posterior  kidney  area  at  the 
angle  between  the  ribs  and  the  spinal  muscles.  With  the  fingers  in  the  loin, 
the  kidney  tumour,  if  small,  can  be  projected  against  the  anterior  hand  by 
a  sudden  push  ("  ballottement ").  Unless  fixed  by  adhesions,  renal  tumours 
descend  with  inspiration,  though  rather  less  freely  than  tumours  of  the 
spleen,  liver,  or  suprarenal  body.  The  tumour  can  usually  be  separated 
from  the  liver,  and  seldom  reaches  the  middle  line. 

Percussion  gives  a  dull  note,  merging  into  that  of  the  spinal  muscles 
behind.  Anteriorly  there  is  a  zone  of  comparative  resonance,  when  the 
colon  lies  on  the  front  of  the  tumour.  If  the  colon  is  collapsed  and  dull  on 
percussion,  it  can  be  rolled  beneath  the  fingers.  On  the  right  side  there 
is  usually  an  area  of  resonance  between  the  renal  dullness  and  that  of  the 
liver. 

EXAMINATION    OF    THE    URINE    OF    EACH    KIDNEY- 
EXPLORATION 

Examination  of  the  urine  of  each  kidney.— The  urine 
of  each  kidney  may  be  obtained  by  the  following  methods : — 

(a)  i*  eparators. — The  principle  of  the  separators  is  the  formation  of  a 
septum  in  the  middle  line  of  the  bladder,  so  that  one  ureter  opens  on  each 
side  of  it,  and  the  draining  of  each  of  these  compartments  separately.  The 
separators  of  Luys  and  Cathelin  are  those  most  commonly  used,  but  they 
have  largely  been  superseded  by  ureteral  catheterization.  In  the  former,  the 
patient  lies  on  the  back  on  an  operating  chair,  and  the  urethra  is  cocainized. 
The  bladder  is  washed,  and  6  or  8  oz.  of  fluid  injected.  The  instrument  is 
passed  ;  in  the  male,  deep  depression  between  the  patient's  thighs  is  necessary 
in  order  to  make  the  curved  portion  of  the  separator  ride  over  the  posterior 
lip  of  the  internal  meatus.  The  patient  is  now  fully  raised  into  a  sitting 
posture  and  the  screw  turned  to  render  the  chain  taut  and  form  a  membrane. 
The  urine  is  collected  in  tubes,  and  the  examination  continued  for  twenty 
or  twenty-five  minutes. 

(b)  Catheterization  of  the  ureters.— A  fine  catheter,  30  in.  in 
length,  is  introduced  into  the  ureter  either  through  a  specially  constructed 
cystoscope  or  through  an  open  tube  under  the  guidance  of  a  reflected  light. 
The  bladder  is  washed  and  distended  with  10  oz.  of  clear  fluid,  and  the  cysto- 
scope, loaded  with  a  catheter,  is  introduced.  The  window  is  manoeuvred 
into  a  position  close  to  the  ureter,  the  catheter  is  gently  inserted  into 
the  opening,  and  pushed  gently  on  for  12  in.  Then  the  other  ureter 
is  catheterized  if  a  double-barrelled  instrument  is  being  used ;  or  if  a  single- 
barrelled  cystoscope  is  being  employed  it  is  withdrawn — leaving  the  first 
catheter  in  position — reloaded  and  reintroduced,  and  the  second  ureter 
catheterized.  In  direct  catheterization  of  the  ureters  (Kelly's  method), 
which  is  only  applicable  to  the  fema)e  bladder,  the  urethra  is  dilated  suffi- 


POLYURIA— ANURIA  781 

ciently  to  permit  the  introduction  of  .1  short  wide  speculum.  The  patient  La 
then  placed  in  the  knee-chest  position,  so  that  the  bladder  becomes  distended 
by  atmospheric  pressure.  Any  fluid  which  remains  in  the  bladder  is  mopped 
up  with  pledgets  of  wooL  Light  is  projected  into  the  bladder  either  from  an 
electric  head-lamp  or  reflected  from  a  forehead  mirror.  The  manipulation 
is  made  directly  through  the  open  tube. 

Exploration  of  the  kidney.— Exploration  of  the  kidney  by 
operation  may  l>o  necessary  in  the  following  cases :  (1)  To  diagnose  abdo- 
minal tumours  of  doubtful  nature.  Laparatomy  will  be  the  best  method. 
(2)  To  ascertain  the  nature  of  disease  already  localized  to  the  kidney. 
An  oblique  lumbar  incision  and  extraperitoneal  examination  of  the  kidney 
is  advisable  for  this  purpose.  (3)  To  ascertain  the  extent  and  connexions 
of  tho  tumour  and  the  condition  of  the  lymphatics  in  a  larue  mail 
growth  of  the  kidney.  Either  a  lumbal-  extraperitoneal  examination  of 
the  kidney  combined  with  an  exploration  through  an  opening  in  the  peri- 
toneum in  front  of  the  colon,  or  a  laparotomy  alone,  may  be  used.  (4)  To 
ascertain  the  presence  and  condition  of  the  second  kidney  when  one  is  diseased 
and  nephrectomy  is  proposed.  For  this  purpose  cystoscopy  and  ureteral 
catheterization  have  replaced  nephrotomy,  which  is  only  required  in  the 
rarest  cases,  when  these  methods  are  rendered  impossible  by  cystitis. 
Access  is  obtained  through  a  lumbar  incision,  and  the  kidney  is  examined 
extraperitoneally  by  inspection,  palpation,  and  incision,  and,  if  necessary, 
a  slip  of  the  kidney  substance  is  removed  and  examined  microscopically. 
The  abdominal  route  only  permits  of  palpation,  and  has  proved  worthless. 

POLYURIA 

Continuous  polyuria  (80  to  100  ounces  in  twenty-four  hours)  is  observed 
in  those  forms  of  chronic  interstitial  nephritis  which  result  from  urinary 
obstruction  or  from  other  conditions,  such  as  calculus  and  tuberculosis. 
that  cause  gradual  destruction  of  renal  tissue.  The  total  quantity  of  urea 
and  other  urinary  solids  is  much  diminished.  Nervous  polyuria  may  be 
transient  or  may  continue  for  some  weeks  or  months  ;  it  is  accompanied  by 
indefinite  abdominal  pain  and  frequent  micturition.  The  renal  function  is 
not  impaired  in  nervous  polyuria. 

OLIGURIA    AND    ANURIA 

Oliguria  is  a  diminished  secretion  of    urine,  anuria   a   total  cessation  of 
the  secretion.     The  types  of  oliguria  and  anuria  may  be  classified  thus : — 
1.  Hysterical  anuria. 
■2.   Anuria  due  to  changes  in  the  general  blood  pressure. 

3.  Reflex  anuria : 

(i)  Urethra. 

(ii)  Bladder, 
(iii)  Ureter, 
(iv)  Kidney. 

4.  Infective  anuria : 

(i)  Hematogenous  -  ("J  *™  .  . 
'  1  (0)    bacterial. 

(ii)  Ascending  urinary. 

5.  Urinary-tension    anuria  : 

m  Obstruction  -'  (a)  g^^y  increasing. 
(i)  instruction  (  (&)   gudden 

(ii)  Sudden  relief  of  hypertension. 


782  THE   KIDNEY 

6.  Anuria  from  destruction  or  removal  of  renal  tissue: 
(i)  Gradual  destruction, 
(ii)  Sudden  complete  destruction  or  removal. 

1.  Hysterical  anuria. — Anuria  may  last  for  several  hours  or  even 
days,  but  no  symptoms  of  ursemia  supervene.  A  copious  polyuria  imme- 
diately follows  the  anuria. 

2.  Circulatory  anuria. — After  severe,  prolonged  operations  temporary 
oliguria  or  anuria  may  result  from  the  low  blood-pressure  of  shock,  and  also 
from  the  effect  of  the  anaesthetic  and  the  absorption  of  antiseptics.  If  the 
kidneys  are  diseased,  this  may  initiate  continuous  and  fatal  anuria.  In 
shock  caused  by  grave  injuries  to  the  body,  and  in  the  collapse  of  cholera, 
anuria  is  present. 

3.  Reflex  anuria. — The  passage  of  urethral  instruments,  especially  if 
roughly  used,  or  if  necessitated  by  disease  in  the  deeper  part  of  the  canal. 
may  be  followed  by  suppression  of  urine.  The  urethra  may  be  healthy  and 
its  mucous  membrane  intact.  The  kidneys  may  show  chronic  nephritis  or 
deep  congestion,  but  sometimes  they  appear  normal.  There  is  usually  a 
rigor  with  rise  of  temperature  to  103°  or  104°  Fahr.  In  the  majority  of 
cases  the  symptoms  are  due  to  septic  absorption,  and  in  some  to  a  combina- 
tion of  septic  absorption  and  a  reflex  effect  on  the  circulation  of  the  kidneys, 
while  in  a  few  they  are  purely  reflex  in  nature. 

Surgical  interference  with  the  bladder  may  be  followed  by  suppression 
of  urine. 

Reflex  impulses  from  a  ureter,  started  by  a  catheter  or  stone,  may  inhibit 
the  secretion  of  the  corresponding  kidney.  The  function  of  both  kidneys 
may  be  suppressed  and  complete  anuria  result  owing  to  the  lodging  of  a 
stone  in  one  ureter  or  the  kinking  of  the  ureter  of  a  movable  kidney.  The 
second  kidney  is  always  diseased.  (See  Calculous  Anuria,  p.  837.)  Disease 
of  one  kidney,  such  as  pyelonephritis,  may  reflexly  cause  oliguria  or  tem- 
porary attacks  of  complete  anuria. 

4.  Infective  anuria,  (i)  Hematogenous. — In  acute  nephritis  caused 
by  a  hsematogenous  infection,  in  septicaemia,  influenza,  pneumonia,  typhoid 
fever,  and  in  auto-intoxication  from  gastro-intestinal  infection,  suppression 
of  urine  is  frequently  present,  and  may  be  fatal.  Anuria  following  urethral 
operations  is  toxic  in  nature  in  many  cases.  In  hsematogenous  infection 
of  the  kidney  with  the  Bacillus  coli  communis  complete  suppression  may 
occur.     (See  Hematogenous  Pyelonephritis,  p.   802.) 

(ii)  Ascending. — An  acute  ascending  infection  of  the  kidneys  may  cause 
fatal  anuria.  Chronic  septic  pyelonephritis  secondary  to  disease  of  the  lower 
urinary  organs  is  accompanied  by  oliguria,  and  complete  anuria  may  super- 
vene.    (See  Ascending  Pyelonephritis,   p.  802.) 

5.  Urinary-preSSUre  anuria. — Complete  anuria  may  follow  the 
sudden  relief  of  urinary  tension  such  as  is  caused  by  the  quick  emptying  of 
an  over-distended  bladder.  Rapid  occlusion  of  both  ureters  by  stone  or 
malignant  disease  also  leads  to  complete  suppression  of  the  renal  function. 
(See  Calculous  Anuria,  p.   8:17  , 

6.  Anuria  from  destruction  or  removal  of  renal  tissue. 
— The  removal  of  a  solitary  kidney,  or  of  the  only  working  kidney,  is 
followed  by  anuria,  and  death  in  a  few  days.  If  the  second  kidney  is 
active,  but  incompetent  from  disease,  the  patient  may  survive  the  operation 
and  die  some  months  afterwards.  Where  the  kidney  is  slowly  destroyed 
by  disease  there  are  attacks  of  partial  or  complete  anuria,  and  finally 
complete  suppressfon. 


BACTERIURIA  783 

Treatment  of  anuria.  Hysterical  anuria  is  treated  by  bromides, 
valerian,  etc.  Diuretics  should  be  administered,  ami  can-  exenised  t<> 
prevent   fraudulent  disposal  of  any  urine  that   1-  passed. 

'  idatory  anuria  is  treated  by  raisin--  the  blood  pressure  by  means  oi 
Btryohnine,  ergot,  adrenalin,  and  pituitary  extract,  and  by  saline  infusion. 
Jn  reflex  anuria  the  cause  of  the  reflex  inhibition  should  be  removed  (see 
Caloulous  Anuria,  p.  s:;t.  and  Pyelonephritis,  p.  801).  Jn  infective  anuria 
it  may  be  accessary  to  incise  one  or  even  both  kidneys  [set  Pyelonephritis), 
Suddt-n  relief  of  long-established  severe  obstruction,  as,  for  example, 
the  complete  emptying  of  a  chronically  over-distended  bladder  in  a  case 
of  enlarged  prostate,  should  be  avoided. 

The  following  measures  should  be  adopted  in  cases  of  anuria:  Diuretics 
are  administered  such  as  caffeine  (5  gr.).  diuretin  (10  gr.),  theocin  Bodium 
acetate  (5  gr.),  bot  Contrex6ville  water,  and  citrate  of  potash  (16  gr.).  Hot 
fomentations  and  poultices  arc  applied  over  the  loins,  or  the  kidneys  may 
be  dry-cupped.  The  patient  is  placed  in  a  hot  pack  or  a  vapour  bath.  In 
sevci  he  introduction  of  one  to  two  pints  or  more  of  glucose  solution 

(2\  per  cent.)  into  a  vein  has  a  powerful  diuretic  effe 

In  urgent  cases  a  pint  of  glucose  solution  (25  per  cent.)  is  infused  into 
a  vein.  This  solution  is  hypertonic  and  increases  the  molecular  content  of 
the  blood.  In  less  urgent  cases  the  injection  may  be  given  suhcutaneously 
or  intramuscularly,  or  introduced  into  the  rectum.  Jeanbrau  recommends 
an  isotonic  solution  of  glucose  (47  grm.  per  1,000),  or  of  saccharose  or  lactose 
(90  grm.  per  1.(300). 

BACTERIURIA    (BACTLLURIA) 

Bacteriuria  (hacilluria)  is  a  condition  of  the  urine  in  which  bacteria  are 
present  in  so  great  abundance  that  they  render  the  fluid  cloudy  to  the  naked 
eye,  yet  inflammatory  products  are  almost  or  entirely  absent.  Bacterial 
growth  is  excessive,  and  reaction  minimal.  Bacteriuria  is  found  in  infants 
and  children,  as  well  as  in  adults.  Women  are  more  frequently  affected 
than  men. 

Pathology. — The  Bacillus  coli  is  present  in  pure  culture  in  over 
SO  per  cent,  of  cases.  The  bacillus  of  typhoid  is  next  most  frequent ; 
frequent  are  the  Staphylococcus  albus,  the  Proteus  vulgaris,  the  Streptococcus, 
and  the  Bacillus  subtilis.  These  bacteria  are  usually  present  in  pure  culture. 
Bacteriuria  may  arise  spontaneously,  or  it  may  complicate  some  urinary 
disease. 

In  spontaneous  cases  a  history  of  constipation  or  indigestion  can  usually 
be  obtained,  and  pronounced  phosphaturia  may  precede  the  bacteriuria. 
Other  predisposing  causes  are  chronic  septic  conditions  of  the  mouth  and 
throat,  operations  upon  the  rectum  or  anus,  boils  or  carbuncles,  appendicitis, 
and  dysentery.  Typhoid  fever  precedes  the  typhoid  form,  and  other  ie\ 
such  as  smallpox,  diphtheria,  scarlet  fever,  and  measles,  may  he  accompanied 
by   bacteriuria. 

Bacteriuria  may  supervene  during  the  course  of  chronic  prostatitis  or 
seminal  vesiculitis,  or  it  may  immediately  follow  the  passage  of  a  sound 
or  catheter.  The  bacteria  gain  admission  to  the  urinary  tract  through  the 
kidneys  (hematogenous  infection),  or  may  be  introduced  into  the  urethra 
or  bladder  by  instrumentation,  or  may  ascend  from  the  urethral  opening 
in  women  and  female  children  (urinary  or  ascending  infection).  The  state- 
ment that  they  may  pass  directly  through  the  rectal  and  bladder  walls  is- 
unsupported    by    direct    evidence.      In    uncomplicated    cases,    post-mortem 


784  THE   KIDNEY 

examination  has  shown  a  complete  absence  of  any  lesion  of  the  urinary 
mucous  membrane. 

Symptoms. — When  passed  the  urine  is  hazy  and  frequently  opalescent 
from  the  suspension  of  myriads  of  bacteria.  On  rotating  a  glass  beaker, 
so  as  to  circulate  the  fluid,  a  peculiar  and  characteristic  appearance  like 
drifting  mist  or  smoke  is  seen.  The  reaction  is  usually  acid,  occasionally 
neutral,  and  rarely  alkaline.  On  centrifugalization,  no  deposit  is  obtained 
and  the  fluid  remains  cloudy.  The  urine  has  usually  a  strong  fishy  odour 
and  contains  a  trace  of  albumin.  Under  the  microscope  the  field  is  crowded 
with  bacteria,  usually  the  motile  Bacillus  coli.  A  few  leucocytes  may  !><• 
found,  and  epithelial  cells  from  t  he  renal  pel  vis,  ureter,  and  bladder,  or  the  pro- 
static urethra.  The  only  constant  sign  is  the  bacterial  emulsion  in  the  urine. 
The  urine  may  remain  constantly  cloudy  for  months  or  years,  or  it  may 
suddenly  clear,   perhaps  to  become  clouded  again  a\  ith  equal  suddenness. 

There  may  be  no  symptoms  at  all,  but  signs  of  localized  inflammation 
are  seldom  entirely  absent.  These  consist  in  increased  frequency  of  micturi- 
tion, and  urgency  or  scalding  on  passing  water.  In  children,  nocturnal 
enuresis  may  result.  Frequently,  if  the  prostatic  urethra  or  the  prostate 
is  the  seat  of  the  bacterial  growth,  the  last  few  drops  of  urine  are  milky  with 
bacterial  emulsion,  while  the  rest  is  merely  hazy.  In  other  eases  the  focus 
of  bacterial  growth  is  confined  to  the  renal  pelvis. 

Prognosis. — In  some  cases  bacteriuria  is  transient  and  appears  for  a 
few  days  only,  rapidly  disappearing  under  treatment.  Usually,  however,  it 
continues  with  exacerbations  and  remissions  for  months  or  years.  During 
this  time  the  health  of  the  patient  may  be  uninfluenced,  but  there  is  the 
constant  danger  of  a  virulent  bacterial  inflammation  arising  in  some  part 
of  the  urinary  tract. 

Treatment. — This  consists  in  the  administration  of  urinary  anti- 
septics and  diluents,  and  in  local  treatment  of  the  focus  of  inflammation 
and  removal  of  the  source  of  bacterial  infection.  Of  urinary  antiseptics  the 
best  are  urotropine  (15-30  gr.  daily),  oil  of  turpentine  (15-30  minims  daily) 
in  capsule,  hetraline  or  helmitol  (30  gr.  daity),  and  salol  (30  gr.  daily).  The 
administration  of  diuretics  and  alkaline  waters  with  these  antiseptics  renders 
the  urine  less  suitable  for  bacterial  growth.  Contrexeville,  Vichy,  or  Evian 
water  may  be  given,  or  the  patient  directed  to  drink  large  quantities  of 
distilled  water  or  barley-water. 

Rovsing  advises  that  a  catheter  should  be  retained  in  the  urethra  for 
a  week  or  more  while  salol  is  administered  by  the  mouth  and  large  quan- 
tities of  distilled  water  are  drunk. 

Where  the  focus  of  bacterial  growth  is  confined  to  the  prostatic  urethra, 
washing  the  bladder  and  urethra  by  Janet's  irrigation  method  may  quickly 
relieve  the  symptoms  and  suppress  the  bacterial  growth.  The  solutions 
suitable  for  this  irrigation  are  permanganate  of  potash  (1  in  10,000  to  1  in 
5,000),  oxycyanide  of  mercury  (1  in  10,000),  and  nitrate  of  silver  (1  in  10,000). 

It  is  of  the  utmost  importance  to  empty  and  regulate  the  bowel  and 
prevent  further  absorption.  A  course  of  artificially  soured  milk  may  be 
continued  for  several  months. 

Anti-coli  horse  serum  has  been  administered  with  some  success  in  acute 
cases  of  Bacillus  coli  infection  of  the  urinary  tract,  and  may  be  tried.  A  dose 
of  25  c.c.  of  the  serum  should  be  injected  subcutaneously  on  three  successive 
days.  If  improvement  has  not  taken  place  at  the  end  of  that  time,  the  treat- 
ment should  be  abandoned.  Calcium  lactate  (20  gr.  thrice  daily)  should  be 
administered  by  the  mouth  to  prevent  the  unpleasant  effects  of  the  serum. 


II  EMATURIA 

Treatment   by  raooines  gives  varying  results.     In  some  oases  the  bacteria 
in  the  urine  rapidly  diminish   in  quantit]    and   in  a    fev<    cases  disappear. 
Vacoines  Bhould  be  autogenous.     In   Bacillus  cob"  infections  small  do 
vaccine  up  to  1"  or  l.">  million  bacteria  are  less  efficacious  than  bighei 
of  from  30  to  50  or  even  LOO  million,  which  Bhould  be  given  at  intervals  "t 
a  week. 

Where  the  bacteriuria  is  superimposed  on  some  pre-existing  disease  of 
tin'  urinary  tract,  the  latter  Bhould  be  suitably  treated. 

1 1.  i:\i.\Tri;  I  a 

An  appearance  resembling  blood  is  given  to  the  urine  in  baa globin 

and  after  the  ingestion  of  Borne  drugs,  such  as  senna,  rhubarb,  sulphonal, 
Che  final  test  for  hsematuria  is  the  microscope.     The  mine  in  bsemo- 
globinuria  has  a  peculiar  purple  colour,  it  contains  no  clots,  and  shows  no 
blood  corpuscles,  even  after  centrifugalizing. 

Localization  of  the  source  of  hematuria.-  Blood  from 

an  area  anterior  to  the  compressor  urethra'  escapes  from  the  meatus  inde- 
pendently of  micturition:  that  from  any  part  behind  this  muscle  is  mixed 
with   the  urine  and  is  only  discharged   with  it. 

I  hematuria  may  he  the  solitary  symptom,  or  it  may  he  accompanied 
by  localizing  symptoms. 

Severe  pain  in  one  kidney  and  ureteric  colic  will  localize  the  hsemon 
to  this  kidney,  renal  pelvis,  or  ureter;  but  dull  aching  in  one  kidney  may 
be  present  in  vesical  disease  such  as  papilloma  and  malignant  growth. 

Pain  at  the  end  of  the  penis  on  micturition  points  to  an  affection  of  the 
base  of  the  bladder,  or  of  the  prostatic  urethra;  while  pain  at  the  base  of 
the  sacrum,  in  the  rectum,  or  in  the  perineum  suggests  the  prostate. 

Frequent  micturition  localizes  the  point  of  haemorrhage  to  the  prostatic 
urethra  or  bladder.  Copious  bleeding  from  the  kidney  may,  however,  cause 
vesical  irritation  and  frequent  micturition. 

The  combination  of  obstruction  and  hsematuria  is  most  frequently  due 
to  prostatic  or  urethral  disease,  but  may  result  from  a  papilloma  of  the 
bladder  near  the  internal  meatus,  or  with  a  long  pedicle,  or  even  from  tem- 
porary impaction  of  a  clot  in  the  urethra. 

The  longer  the  blood  remains  in  contact  with  the  urine,  the  more  likely 
is  it  to  be  discoloured.  The  higher  the  source  of  blood  in  the  urinary  tract, 
the  better  the  admixture  with  the  mine.  Blood  in  a  highly  acid  urine  is 
brownish,  and  in  an  alkaline  urine  bright  red. 

A  brownish  or  smoky  appearance  of  the  urine  indicates  that  the  blood 
is  small  in  quantity,  well  mixed  with  the  urine,  and  the  reaction  acid.  Such 
bleeding  is  usually  renal  in  origin,  and  only  forms  a  sediment  after  several 
hours.  In  coffee-coloured  urine  the  source  of  bleeding  is  frequently  the 
kidney  or  kidney  pelvis,  but  may  be  the  bladder  or  the  prostate,  especially  if 
there  is  urethral  obstruction.  A  purple  tinge  denotes  venous  bleeding,  which 
may  Vie  derived  from  any  part  of  the  urinary  tract.  If  the  urine  has  a  delicate 
pink  colour,  the  blood  usually  comes  from  the  bladder  or  the  prostatic  urethra. 
Bright-red  blood  indicates  copious  bleeding  from  an  arterial  source,  and  may 
arise  in  any  part  of  the  urinary  tract,  most  frequently  in  the  bladder  or  prostate. 

Blood  appearing  at  the  beginning  of  micturition  (initial  hematuria) 
usually  comes  from  the  prostatic  urethra.  Terminal  hsematuria  (appearing 
at  the  end  of  micturition)  is  derived  from  the  prostatic  urethra  or  the  bladder. 
No  inference  can  be  drawn  as  to  the  source  of  blood  mixed  with  the  whole 
of  the  urine  (total  hsematuria). 


THE   KIDNEY 

Slender  worm-like  clots,  1"  or  12  in.  in  length,  are  sometimes  passed, 
and  indicate  the  kidney  or  renal  pelvis  as  the  source  of  bleeding.  More 
frequently,  however,  the  clots  passed  from  the  ureter  are  small  plugs,  i  in. 
in  length.  The  blood  may  be  rapidly  passed  into  the  bladder  and  there 
form  irregular  masses  or  flat  clots,  which  indicate  the  position  of  coagulation, 
but  not  the  source  of  the  haemorrhage.  Urethral  bleeding  may  form  a  cast 
of  the  urethra,  which  is  discharged  with  the  urine. 

Albumin  is  present  even  where  the  amount  of  blood  is  very  small.  In 
cases  of  renal  haematuria.  however,  the  quantity  of  albumin  exceeds  the 
amount  corresponding  to  the  admixture  of  blood.  If,  on  estimation,  excess 
of  the  albumin  over  the  proportion  of  1*6  to  1  of  haemoglobin  be  found,  this 
points  to  a  renal  cause  of  the  haeniaturia  (Xewman). 

In  renal  ha?maturia  the  corpuscles  often  appear  as  pale  discs  almost 
devoid  of  colouring  matter,  while  those  added  to  the  urine  in  the  lower 
urinary  tract  are  less  changed. 

Casts  of  the  renal  tubules,  if  present,  indicate  a  renal  lesion.  Epithelial 
■  ells  from  the  kidney,  pelvis,  and  ureter,  bladder,  or  urethra  may  be  dis- 
covered and  help  to  localize  the  source  of  the  haemorrhage. 

The  kidneys,   ureters,   and  bladder  should  be  examined  by  abdominal 
palpation,  and  the  prostatic  and  membranous  urethra,  the  prostate,  seminal 
les,  bladder  base,  and  lower  ureters  examined  from  the  rectum. 

■ami nation  supplies  a  means  of  certain  localization.  The 
bladder  is  thus  examined  for  growths  or  ulcers,  and  the  ureteric  orifices  for 
evidences  of  disease  or  staining  of  the  efflux.  Finally,  the  ureters  should 
be  catheterized.  and  a  sample  of  urine  obtained  from  each  kidney  for 
microscopical  examination  (p.  780). 

The  diagnosis  of  the  cause  of  haematuria  will  be  de- 
scribed under  the  various  diseases,  but  one  form  which  cannot  be  referred 
to  any  single  disease  must  be  discussed  here. 

Essentia!  renal  haematuria. — This  name  has  been  given  to  a  group 
"f  cases  where  haematuria  has  been  localized  to  one  kidney.  Careful  micro- 
scopical examination  of  these  kidneys  frequently  gives  evidence  of  some 
degree  of  chronic  nephritis ;  this  occurs  in  scattered  patches,  however,  and 
may  therefore  easily  be  overlooked.  A  few  cases  have  been  recorded  in 
which  haeniaturia  without  other  symptoms  and  without  albuminuria  has  been 
caused  by  a  more  extensive  unilateral  chronic  nephritis  (Poirier,  Loumeau). 

A  varicose  condition  of  one  or  more  of  the  renal  papillae  as  a  cause  of 
haematuria  has  been  described  by  Femvick.  Whitney,  Pilcher,  and  others. 
Its  origin  is  doubtful ;  possibly  it  may  result  from  a  patch  of  interstitial 
nephritis  similar  to  the  condition  just  described.  Profuse  unilateral  renal 
haematuria  unaccompanied  by  other  symptoms  may  be  met  with  as  a  pre- 
monitory or  early  Bymptom  of  chronic  Blight's  disc 

Essential  haematuria  is  spontaneous,  strictly  unilateral,  and  is  not  affected 
by  rest  or  movement.  The  blood  is  abundant  and  well  mixed,  and  gives  the 
urine  a  dark,  port-wine  colour.  Clots  are  very  rarely  formed.  The  bleeding 
may  suddenly  cease  after  some  weeks  or  months,  and  may  as  suddenly 
reappear  and  become  persistent.  In  the  intervals  no  albumin  can  be  detected 
nor  tube  casts  found.  Xo  bacteria  are  present  in  the  urine.  On  the 
affected  side  there  is  occasionally  a  dull  aching  pain,  uninfluenced  by  move- 
ment.    The  kidney  is  not  tender  or  enlar_ 

In  13  cases  of  unilateral  symptomless  haematuria  in  which  I  explored  the 
kidney  and  removed  a  portion  for  examination,  the  microscope  showed 
cortical  patches  of  fibrosis  in  all,  of  varying  size.     Xewman  has  recorded  a 


II  i:\I.\Tl  Kl\     PYURIA  787 

case  of  Bevere  renal  hematuria  which  preceded  other  symptoms  of  tuberculouB 
disease  by  two  years.  Symptomless  bsematuria  may  occur  in  some  growths 
of  the  kidney  at  a  rory  early  Btage  of  their  development! 

Treatment  of  haematuria.  -Only  exceptionally  is  treatmenl  for 
bsematuria,  apart  from  operative  measures,  required.   Morphia,  gotine, 

tincture  of  hamamelis,  and  calcium  chloride  or  lactate  may  be  used. 

Local  treatment. — In  renal  hcematuria  dry  cupping  and  ice-hags  may 
be  applied  over  the  kidney.  Adrenalin  has  been  injected  into  the  renal  pelvis 
through  a  ureteric  catheter,  1  drachm  of  l-in-5,000  solution  being  used. 

In  vesical  "hcematuria  a  catheter  should  he  passed  and  the  bladder  washed 
out  with  large  quantities  of  hot  boric  solution  or  of  a  hot.  very  weak  Bolution 
(1  in  15,000)  of  silver  nitrate.  Afterwards  10  or  12  oz.  of  a  solution  of  anti- 
pyrin  (10  per  cent),  or  1  or  2  drachms  of  adrenalin  solution  (1  in  2,000),  are 
injected  into  the  Madder,  left  for  a  few  minutes,  and  then  run  out.  Any 
clots  in  the  bladder  may  be  washed  out  through  a  large  catheter,  or,  better, 
through  a  large  evacuating  catheter  such  as  is  used  in  lithotrity.  The  rubber 
lithutrity  bulb  may  be  attached  and  the  clots  sucked  out.  These  methods 
should  not  be  persisted  in  for  long ;  if  the  clots  are  large,  and  distending 
the  bladder,  suprapubic  cystotomy  should  be  performed,  the  clots  cleared 
out,  and  a  stream  of  hot  boric  solution  (115°  to  120°  F.)  passed  through  a 
catheter  in  the  urethra,  and  allowed  to  well  out  of  the  suprapubic  opening. 

In  a  case  of  unilateral  renal  hcematuria  nephrotomy  is  necessary,  and  if  a 
papilla  of  the  kidney  shows  congestion  it  may  be  cut  away  with  a  sharp 
spoon.  Where  nephrotomy  fails  to  discover  any  lesion  in  the  renal  substance 
the  wounds  in  the  kidney  and  renal  pelvis  should  be  closed  with  catgut 
sutures.  The  haematuria  in  the  majority  of  eases  ceases  after  the  exploration, 
apparently  as  a  result  of  pressure  upon  the  bleeding  vessel  by  the  sutures. 
Nephrectomy  should  not  be  performed  for  this  reason,  and  also  because 
bilateral  nephritis  may  give  rise  to  unilateral  bsematuria.  Very  rarely  recur- 
rence of  haemorrhage  necessitates  a  second  operation. 

Decapsulation  inay  be  combined  with  nephrotomy,  but  the  results  are 
similar  to  those  of  nephrotomy  alone,  the  haematuria  recurring  in  rare  cases. 

PYURIA 

Pyuria  indicates  inflammation  in  one  or  more  parts  of  the  urinary 
tract.  Bacterial  infection  may  occur  in  an  otherwise  healthy  urinary  tract, 
or  may  be  superadded  to  stone,  stricture,  growth,  or  other  gross  lesions. 
Further,  one  bacterial  inflammation  may  be  superimposed  upon  another  of 
a  different  ehai'acter. 

Apart  from  acute  inflammation  of  the  urethra,  the  position  of  which 
will  be  evident  from  the  discharge  of  pus  at  the  meatus,  the  largest  quantities 
of  pus  are  derived  from  purulent  collections  in  the  kidney.  In  cases  of  long- 
standing bladder  inflammation  the  total  quantity  of  deposit  may  be  large, 
but  the  proportion  of  pus  is  not  so  great.  The  fluffy  muco-purulent  deposit 
of  urethritis  settles  quickly  to  the  bottom  of  the  glass,  while  that  of  cystitis 
forms  billows  in  the  urine,  which  is  usually  highly  coloured  and  concentrated. 
In  severe  old-standing  cystitis  the  urine  may  be  like  coffee  with  milk.  The 
sediment,  after  standing  for  an  hour  or  two.  is  viscous  and  clings  like 
slime  to  the  bottom  of  the  vessel.  Pus  from  the  renal  pelvis,  or  from 
a  dilated  kidney,  produces  a  milky  urine  when  passed,  but  later  lies  at  the 
bottom  as  a  heavy,  flat,  yellowish  layer,  which  rolls  heavily  to  the  lowest 
part  when  the  vessel  is  canted.  The  supernatant  fluid  is  cloudy  with  sus- 
pended pus  or  bacteria. 


7SS  THE   KIDNEY 

The  urine  is  usually  pale  and  of  low  specific  gravity.  Suppurative  renal 
disease  combined  with  cystitis  produces  a  solid  layer  of  pus  at  the  bottom 
of  the  glass,  and  above  this  a  layer  of  billowy,  fluffy  muco-pus. 

In  chronic  cystitis  the  urine  has  a  pungent  ammoniacal  odour.  As  a 
rule,  purulent  urine  from  the  kidney  has  no  characteristic  odour,  but  a  puru- 
lent collection  in  a  dilated  kidney  may  be  offensive,  and  a  pyelitis  with  exces- 
sive bacterial  growth  may  possess  a  very  strong  disagreeable  and  penetrating 
smell.  Bacillus  coli,  the  gonococcus,  and  Bacillus  typhosus  produce  acute 
cystitis,  in  which  the  purulent  urine  remains  acid.  The  tubercle  bacillus 
produces  a  subacute  or  chronic  cystitis  with  an  acid  urine.  The  staphylo- 
coccus, streptococcus,  and  Bacillus  proteus  cause  ammoniacal  decomposi- 
tion of  the  urine.  The  urine  from  a  case  of  suppurative  pyelitis  is  usually 
acid,  but  ammoniacal  decomposition  may  take  place. 

Pus  appearing  at  the  beginning  of  micturition  has  a  urethral  origin. 
When  the  urine  is  clear  at  the  beginning  of  micturition  and  purulent  at  the 
finish,  the  pus  comes  from  the  prostate  or  bladder. 

Intermittent  pyuria  is  found  in  pyonephrosis,  and  also  when  an  abscess 
or  an  infected  vesical  diverticulum  rejieatedly  discharges  into  the  urethra  or 
bladder. 

Albumin  proportional  to  the  quantity  of  pus  present  is  found  in  the 
urine  of  all  uncomplicated  cases  of  pyuria.  If  it  be  present  in  excessive 
quantities,  renal  complications  may  be  suspected. 

Epithelial  elements  may  be  present  in  the  urine,  but  have  less  significance 
in  regard  to  localization  here  than  in  hseniaturia.  Tube  casts  are  only  found 
in  the  slighter  forms  of  pyelonephritis. 

Localizing  symptoms  may  be  present  which  point  to  the  source  of  the 
pyuria.  The  cystoscope  will  frequently  localize  the  otherwise  obscure  origin 
of  pyuria.  The  examination  of  the  ureteric  orifices  should  never  be  neglected. 
Disease  of  the  bladder  exclusively  surrounding  one  ureteric  orifice,  changes 
at  the  orifice  itself,  and  the  observation  of  murky  or  purulent  urine  coming 
from  one  ureter  will  show  that  there  is  disease  of  the  kidney,  whether  renal 
symptoms  be  present  or  not.  When  the  quantity  of  pus  in  the  urine  is  small 
and  the  bladder  inflamed  it  may  be  very  difficult  to  distinguish  the  pyuria 
by  examining  the  ureteric  efflux,  and  ureteral  catheterization  will  then 
become  necessary.  When  the  pus  is  present  in  quantity  with  little  urine, 
pipes  of  semi-solid  pus  are  observed  issuing  from  the  ureteric  orifice. 

In  some  cases  of  long-standing  pyuria,  radiography  shows  the  presence 
of  stones  in  one  or  both  kidneys,  when  no  symptoms  of  their  presence  have 
been  observed. 

PNEUMATURIA 

In  this  condition  gas  is  discharged  with  the  urine  at  the  end  of  micturi- 
tion. Pneumaturia  may  result  from  the  introduction  of  air  into  the  bladder 
during  instrumentation,  from  the  escape  of  intestinal  gas  through  a  vesico- 
intestinal fistula,  or  rarely  from  spontaneous  development  of  gas  in  the 
urinary  tract.  This  may  be  due  to  Liberation  of  C02  by  fermentation  of 
sugary  urine  through  the  action  of  Bacillus  coli,  or  occasionally  Proteus 
vulgaris  ;  in  non-glycosuric  cases  the  gas  has  been  said  to  be  derived  from 
the  blood  or  from  gaseous  decomposition  of  the  urine  by  gas-producing 
bacteria  such  as  the  colon  bacillus. 

Treatment. — When  no  fistula  exists,  treatment  consists  in  removing 
the  cause  of  the  fermentation  by  washing  the  bladder  and  administering 
urinary  antiseptics.  Glycosuria  should  be  treated.  The  treatment  of  fistula 
of  the  bladder  will  be  discussed  later  (p.  878). 


SOLITARY    KIDNE1  789 

CONGENITAL    ABNORMALITIES    OF    THE    KIDNKY 
AND    ORETEB 

Foeta]  lobulation  of  the  kidneys  occasionally  persists  throughout  life. 
Complete  absence  of  both  kidneys  lias  been  found  in  acephalio  foetuses. 
Supernumerary  kidneys  arc  rare,  A  third  kidney  has  occasionally  been 
found. 

Absence  or  Atrophy  op  One  Kidney 

In  93  cases  which  .1  collected  <>f  death  from  uraemia  or  anuria  after  an 
operation  on  one  kidney,  the  second  kidney  was  absent  in  10  and  com- 
pletely "■atrophied"  in  8.  I'nsymmetrical  kidney  and  extreme  congenital 
atrophy  of  the  kidney  occurs  in  I  in  "2,400  bodies  (Morris).  The  left  kidney 
is  more  frequently  absenl  than  the  right,  and  male  subjects  are  more 
often  affected  than  female  in  the  proportion  of  2  to  1.  The  renal  vessels 
on  the  affected  side  are  absent  or  rudimentary,  and  the  ureter  is  absent 
(93  per  cent.)  or  is  represented  by  a  solid  fibrous  cord  attached  to  the  bladder. 
The  corresponding  half  of  the  vesical  trigone  is  atrophied.  The  ureteric 
orifice  may  be  undiscoverable,  but  occasionally  shows  as  a  small  dimple  or 
even  as  an  opening  into  a  lumen  extending  from  1  to  2  cm.  In  70 -8  per  cent, 
of  cases  there  is  some  associated  congenital  malformation  in  the  genital 
system,  almost  always  on  the  same  side.  Other  congenital  malformations 
have  also  been  noted,  such  as  hare-lip,  web-fingers,  etc. 

The  solitary  kidney  is  usually  larger  than  normal,  Iobulated,  and  often 
globular  or  irregular  in  shape.  The  single  ureter  enters  the  bladder  in  the 
usual  position,  or  is  displaced  towards  the  middle  line  or  to  some  abnormal 
position  such  as  the  urethra. 

Extreme  congenital  atrophy  is  very  rare,  but  a  less  complete  form  is 
more  frequently  observed.  The  condition  is  usually  due  to  loss  of  function 
of  the  kidney  from  blocking  of  the  ureter  or  disease  of  the  kidney  itself. 
In  congenital  atrophy  some  rudiment  of  the  kidney  is  always  found,  and 
the  ureter  is  present,  although  sometimes  merely  as  a  fibrous  cord. 

Dangers  and  diagnosis  of  solitary  kidney.— A  single 
kidney  is  prone  to  be  attacked  by  disease  such  as  calculus,  malignant  growths. 
tuberculosis,  and  chronic  nephritis.  Apart  from  this,  however,  the  condition 
does  not  shorten  life. 

It  is  imperative  that  proof  of  the  presence  of  an  active  second  kidney 
be  obtained  whenever  nephrectomy  is  proposed.  Congenital  malformation 
of  the  generative  organs  is  present  in  70-8  per  cent,  of  these  cases,  and  should 
lead  to  a  thorough  investigation  of  the  second  kidney. 

On  cystoscopy  the  ureteric  orifice  is  absent  in  33  per  cent,  of  cases.  When 
a  ureteric  orifice  is  present  the  ureter  should  be  catheterized.  Finally,  lumbar 
exploration  of  the  kidney  should  be  carried  out  when  the  previous  methods 
have  failed.     Abdominal  exploration  has  proved  fallacious. 

Fused  Kidneys 

Fusion  of  the  kidneys  into  one  mass  gives  rise  to  an  organ  presenting  a 
great  variety  of  sizes  and  shapes.  The  lowest  degree  of  fusion  is  when  two 
kidneys  are  united  by  a  fibrous  band,  and  the  highest  when  two  kidneys  are 
indistinguishably  fused  in  a  single  mass.  The  following  names  have  been 
applied  to  the  various  shapes,  viz.  horse-shoe  kidney.  S-shaped  kidney,  long 
kidney,  shield-like  kidney,  discoid  kidney. 

The  horse-slioe  kidney  is  the  most  common  degree  of  fusion — 1  in  1,000 
bodies  (Morris).     The  kidneys  are  united  by  a  band  passing  between  the 


79o  THE   KIDNEY 

lower  poles  across  the  aorta  and  vena  cava.  The  fused  kidneys  lie  nearer 
the  middle  line  than  normal  and  are  displaced  downwards,  the  uniting  band 
frequently  lying  as  low  as  the  bifurcation  of  the  aorta.  The  bond  of  union 
varies  from  a  flat  band  of  fibrous  tissue  to  a  definite  bridge  of  renal  tissue. 
The  blood-vessels  of  each  kidney  are  frequently  increased  in  number  and 
abnormal  in  distribution;  the  ureters  pass  down  in  front  of  the  uniting 
band.  Diagnosis  depends  upon  the  discovery  of  a  horse-shoe-like  swelling 
in  front  of  the  lumbar  vertebra',  and  the  discovery  of  a  hydronephrosis  or 
of  shadows  of  calculi  which  lie  nearer  the  middle  line  than  usual.  This 
malformation  has  been  mistaken  for  a  malignant  growth. 

In  unilateral  fused  kidney  the  ureters  may  open  in  the  normal  position 
and  lead  to  the  view  that  two  normal  kidneys  are  present. 

The  course  of  the  ureters  can  be  demonstrated  by  passing  into  each  a 
bougie  opaque  to  the  X-rays. 

Fixed  Misplacement  of  the  Kidxey 

The  fixed  misplaced  kidney  is  occasionally  normal  in  size  and  contour. 
but  usually  shows  considerable  malformation.  The  remaining  kidney,  if 
not  fused,  is  sometimes  absent  or  atrophied. 

The  misplaced  kidney  is  found  at  the  bifurcation  of  the  aorta,  on  the 
promontory  of  the  sacrum,  over  the  sacro-iliac  synchondrosis,  in  the  iliac 
fossa,  or  the  hollow  of  the  sacrum.     The  suprarenal  capsule  accompanies  it. 

If  one  kidney  only  is  misplaced,  it  is  usually  the  left.  The  renal  vessels 
are,  as  a  rule,  abnormal  in  origin,  number  and  distribution ;  malposition  of 
the  colon  and  rectum  and  genital  malformations  are  frequently  present. 

Symptoms  and  diagnosis. — Disease  of  a  misplaced  kidney  fre- 
quently gives  rise  to  pain  in  the  corresponding  lumbar  region,  and  this  may 
distract  attention  from  the  real  cause  of  the  s\Tnptorn.  Renal  misplacement 
seldom  causes  symptoms  per  se.  In  women  a  pelvic  kidney  may  disturb 
menstruation,  pregnancy,  and  parturition.  The  diagnosis  will  rest  upon  the 
discovery  of  a  tumour  on  the  promontory  or  in  the  pelvis,  the  absence  of 
the  kidney  from  the  same  side,  and  sometimes  upon  signs  of  renal  disease 
in  the  urine.  Tumours  of  the  pelvic  organs,  especially  ovarian  cysts,  and 
also  hydatid  cysts  must  be  excluded.  The  rectum  may  be  shown  by  air  in- 
flation to  pursue  an  abnormal  course.  A  very  short  ureter  has  been  observed  on 
catheterization.  Psychic  disturbances  have  been  noted.  A  doubtful  tumour 
in  this  situation  usually  necessitates  a  laparotomy  for  diagnosis. 

Treatment. — When  the  existence  of  a  second  efficient  kidney  has 
been  certainly  ascertained,  the  presence  of  pronounced  symptoms  justifies 
removal  of  the  misplaced  organ. 

CONGENITAL    ABNORMALITIES    OF   THE    RENAL   PELVIS 
AND    URETER 

The  renal  pelvis  may  bifurcate  into  its  upper  and  lower  branches  before 
entering  the  renal  hihun.  or  may  even  sometimes  show  a  third  primary 
division.  Unilateral  duplication  of  the  ureter  occurs  in  •!  per  cent,  of  bodies  ; 
it  may  affect  a  part  or  the  whole  length  of  the  tube,  which  may  open  into 
the  bladder  by  one  or  two  apertures. 

The  ureter  which  drains  the  upper  part  of  the  kidney  usually  crosses 
that  from  the  lower  part,  and  opens  lower  on  the  trigone. 

Bilateral  double  ureters  are  of  less  frequent  occurrence.  Five  and  even 
six  ureters  have  been  found  in  one  individual. 


MOVAB1  E    kIDM  \ 

The  ureter  may  be  congenitally  misplaced  and  open  into  the  male 
tatic  urethra  or  Beminal  vesicle,  into  the  female  urethra  or  vagina,  "i  into 
the  rectum.  The  misplaced  ureter  is  usually  a  supernumerary  one,  and  th< 
ureteric  orifice  is  narrowed  and  sometimes  ends  blindly  in  the  form  of  a 
oysl  in  Borne  pari  of  the  bladder  wall.  Jn  the  female  Bubject,  incontinence  of 
urine  while  the  patient  could  pass  a  quantity  of  water  voluntarily  uas  been 
noted  when  a  ureter  opened  into  the  urethra.  The  ureter  Bhould  be  trans- 
planted  into  the  bladder  in  Bucb  i 

Congenital  narrowing  of  the  ureter  leads  to  hydronephrosis  rophy 

of  the  kidney. 

MOVABLE    AND    FLOATING    KIDNEY 

The  normal  respiratory  excursion  of  the  kidney  varies  from  h  to 
U  in. 

Pathological  anatomy. — A  floating  kidney  is  entirely  sur- 
rounded by  peritoneum,  which  also  clothes  its  pedicle  and  forms 
a  mesonephros.  It  is  a  very  rare  congenital  malformation,  and  cannot 
be  diagnosed  from  a  movable  kidney  without  operation  :  an  intra- 
peritoneal operation  is  required  for  its  relief.  A  movable  kidney  moves 
within  the  thickened  perirenal  fascia  behind  the  peritoneum.  The 
delicate  perirenal  fat  is  diminished  or  entirely  absent,  and  the  fibrous 
threads  connecting  the  fibrous  capsule  of  the  kidney  with  the  perirenal 
fascia  are  thickened.  Milky  patches  of  thickening  are  frequently 
observed  on  the  fibrous  capsule.  The  renal  vessels  are  elongated,  the 
artery  more  so  than  the  vein.  The  suprarenal  body  does  not  move 
with  the  kidney.  The  attachments  of  the  kidney  to  the  duodenum 
and  the  ascending  colon  on  the  right  side  and  to  the  pancreas  and 
the  descending  colon  on  the  left  are  usually  separated.  Thick  bands 
of  adhesions  between  the  kidney  and  colon  may.  however,  be  found. 
The  kidney  occasionally  becomes  adherent  in  an  abnormal  position 
such  as  the  iliac  fossa. 

Torsion  of  the  vascular  pedicle  may  occur  even  when  the  excu 
of  the  kidney  is  moderate.     The  renal  vein  is  obstructed,   and  the 
organ  becomes  engorged  with  blood,  enlarged,  and  dark  purple  with 
subcapsular  haemorrhages. 

Kinking  or  twisting  of  the  ureter  may  be  caused  by  swinging  of 
the  kidney,  or  by  its  rotation  on  its  transverse  axis  and  twisting  of 
the  ureter  over  the  renal  vessels.  The  pelvis  becomes  distended  with 
urine.  Repetition  of  such  attacks  induces  hollowing  of  the  kidney 
and  intermittent  hydronephrosis. 

Undue  mobility  of  the  kidney  may  exist  alone  or  may  be  merely 
part  of  a  general  visceroptosis.  The  stomach  is  frequently  dilated. 
Movable  kidney  may  be  the  seat  of  interstitial  nephritis,  stone,  tuber- 
culosis, or  new  growth. 

Etiology. — The  average  ageis33i  years  (Mc Williams).  Movable 
kidney  occurs  in  from  5  to  10  per  cent,  of  women  and  from  h  to  1  per 


792  THE    KIDNEY 

cent,  of  men.  The  right  kidney  is  affected  in  8  out  of  every  10  cases. 
Both  kidneys  are  affected  in  5  per  cent,  of  cases.  No  single  cause 
satisfactorily  explains  the  occurrence  of  abnormal  mobility  of  the 
kidney  in  all  cases.     The  following  factors  are  of  importance  : — 

1.  Congenital  mobility  is  rarely  observed. 

2.  Anatomical  factors. — The  kidneys  lie  in  shallow  recesses,  one  on 
each  side  of  the  vertebral  bodies,  the  paravertebral  fossa?.  Wolkow  and 
Delitzen  state  that  persons  with  movable  kidneys  have  shallow  para- 
vertebral fossa?  which  are  open  at  the  lower  end.  In  women  they  are 
shallower  and  more  open  than  in  men,  and  on  the  right  side  more 
than  on  the  left. 

Mansell-Moullin  holds  that  there  is  a  slight  rotation  of  the  vertebra? 
to  the  right  in  a  large  number  of  right-sided  people,  and  this  makes 
the  right  lumbar  recess  shallower. 

The  liver  does  not  cause  downward  displacement  of  the  right  kidney. 

3.  Atrophy  of  the  perirenal  fat  is  found  in  many  cases. 

4.  Weakness  of  the  abdominal  walls. — Glenard  states  that  general 
visceroptosis  always  accompanies  movable  kidney  and  results  from 
weakness  of  the  abdominal  wall.  This  is  disproved  by  statistics  and 
experience. 

5.  Injury  and  pressure. — In  11  "4  per  cent,  of  cases  there  is  a  distinct 
history  of  a  blow,  severe  muscular  strain,  or  other  injury  in  the  region 
of  the  kidney.  The  wearing  of  corsets  does  not  produce  movable 
kidney. 

G.  Drag  of  adhesions  between  kidney  and  bowel. — Bands  of  adhesions, 
probably  the  result  of  chronic  constipation,  pass  between  the  kidney 
and  the  colon,  and  the  drag  of  these  is  a  cause  of  movable  kidney 
(Arbuthnot  Lane). 

7.  Pathological  conditions  of  the  kidney. — Tumours,  hydronephrosis, 
calculus,  and  other  diseases  may  coexist  with  movable  kidney,  and 
in  some  cases  appear  to  be  a  factor  in  the  causation  of  the  mobility. 

Clinical  features. — Mobility  of  the  kidney,  even  with  wide 
range  of  movement,  may  be  unaccompanied  by  symptoms. 

1.  Symptoms  referred  to  the  kidney,  (a)  Pain  and  dis- 
comfort.— There  is  renal  pain  of  a  heavy,  aching  character,  and  attacks 
of  acute  pain  may  occur,  followed  by  enlargement  and  tenderness 
of  the  kidney.  The  pain  is  initiated  and  aggravated  by  movement 
and  relieved  by  rest ;  it  is  increased  during  the  menstrual  period. 

(b)  Undue  mobility. — In  slight  degrees  of  mobility  the  kidney 
usually  moves  parallel  with  the  vertebral  column,  but  it  may  swing 
round  so  that  the  lower  pole  approaches  the  bodies  of  the  vertebra? — 
"  cinder-sifting  movement  "  (Morris).  In  another  form  the  upper  end 
of  the  kidney  falls  forward,  while  the  lower  end  remains  in  contact 
with  the  posterior  abdominal  wall.     In  the  wider  ranges  of  movement 


MOVABLE    KIDNEY:   SYMPTOMS  793 

the  kidney  descends  below  the  costal  margin,  at  firsl  vertically,  and 
then  the  lower  pole  swings  towards  the  vertebral  column  so  that  the 
liiluin  facos  upwards.  Exceptionally,  the  pedicle  is  so  long  thai  the 
kidney  may  be  found  in  almost  any  pari  of  the  abdomen,  and  may 
descend  into  t  be  true  pelvis. 

The  movable  kidney  is  uninfluenced   by  respiratory  movements, 

and   escapes  from  the  grasp   with   a   sudden   slip   that    is  characteristic, 

the  patient  experiencing  a  sickening  sensation.  The  tumour  can  be 
reduced  into  the  loin,  and  is  then  no  longer  palpable. 

(c)  Some  lack  of  resistance  is  detected  in  the  loin  of  the  affected 
side  when  the  patient  is  examined  on  her  hands  and  knees. 

(</)  Enlargement  of  the  kidney. — Intermittent  hydronephrosis  not 
infrequently  results  from  abnormal  mobility. 

(e)  Changes  in  the  urine. — Hematuria  is  rare,  but  it  may  follow 
muscular  exertion.  Albuminuria  is  frequently  observed,  and  dis- 
appears on  resting.  Tube  casts  due  to  venous  congestion  are  present 
in  the  urine  in  8  out  of  180  cases  (Newman).  Transient  polyuria  co- 
incides with  the  relief  of  an  attack  of  hydronephrosis.  Anuria  may 
result  from  torsion  of  the  renal  pedicle,  and  has  been  known  to  last 
for  nine  days  without  ill  after-effects. 

Frequent  micturition  may  be  reflex  during  an  attack  of  pain,  or 
the  result  of  polyuria  after  an  attack  of  hydronephrosis. 

2.  Symptoms  referred  to  other  organs,  (a)  Gastro-intestinal 
symptoms. — There  may  be  epigastric  pain  and  burning  unconnected 
with  the  taking  of  food.  The  patient  complains  of  a  sinking  sensation. 
loss  of  appetite,  nausea,  eructations,  a  feeling  of  distension,  and  vomit- 
ing, and  becomes  thin  and  anaemic.  In  such  cases  the  stomach  is 
usually  distended,  and  may  be  displaced  ;  the  right  kidney  is  movable 
and  the  condition  is  due  to  the  drag  of  adhesions  on  the  second  part 
of  the  duodenum  or  of  a  thickened  band  of  peritoneum  on  the  pylorus. 
Recurrent  attacks  of  flatulent  distension  of  the  colon  and  constipation, 
perhaps  resembling  intestinal  obstruction,  may  be  caused  by  adhesions 
between  the  kidney  and  large  intestine.  Jaundice,  epigastric  pain,  and 
distension  of  the  gall-bladder  may  repeatedly  occur  ;  they  have  been 
ascribed  to  pressure  of  the  kidney  on  the  common  bile-duct,  or  to 
dragging  of  the  kidney  upon  the  second  part  of  the  duodenum. 

(6)  Nervous  symptoms. — Mobility  of  the  kidney  is  often  accom- 
panied by  neurasthenia  of  various  degrees,  and  is  considered  by 
Suckling  to  be  a  cause  of  some  forms  of  insanity. 

Dietl's  crises. — The  patient  is  liable  to  crises  which  may  be  due  to 
dragging  on  adhesions  connected  with  the  pylorus  or  bowel  or  to  torsion 
of  the  vascular  pedicle  or  kinking  of  the  ureter.  The  attack  may 
follow  a  muscular  effort,  (a)  When  the  stomach  or  bowel  is  affected 
there  is  severe  epigastric  or  general  abdominal  pain.     Vomiting  and 


794  THE    KIDNEY 

collapse  are  usual.  The  abdominal  muscles  are  rigid,  especially  on 
the  side  of  the  movable  kidney.  Later,  the  abdomen  becomes  dis- 
tended and  tympanitic.  The  bowels  are  constipated,  and  the  tem- 
perature may  be  raised,  (b)  When  the  ureter  is  obstructed  the  kidney 
becomes  large  and  tender,  the  urine  is  diminished,  and  there  may 
be  complete  anuria.  The  attack  lasts  some  hours  or  even  days, 
(c)  With  torsion  of  the  renal  pedicle  there  are  again  acute  abdominal 
symptoms.  In  addition  the  urine  becomes  scanty,  albuminous,  and 
sometimes  bloody,  and  complete  suppression  may  supervene.  The 
kidney  is  painful,  large,  and  tender.  Polyuria  may  follow  the  attack, 
and  the  urine  contains  blood,  and  hyaline,  granular,  and  blood  casts. 

Diagnosis. — The  following  conditions  may  give  rise  to  difficulty 
in  diagnosis  : — 

1.  A  distended  gall-bladder. — The  presence  of  jaundice,  the  con- 
stantly palpable  tumour,  the  restricted  range  of  movement,  the  area  of 
dullness  blending  with  that  of  the  liver,  the  absence  of  a  bowel  note  in 
front  of  the  tumour,  are  characteristic  of  the  distended  gall-bladder. 

2.  RiedeVs  lobe  of  the  liver. — The  respiratory  movement  is  the  same 
as  that  of  the  liver,  and  greater  than  that  of  the  kidney,  the  dullness  is 
continuous  with  that  of  the  liver,  and  the  edge  of  the  swelling  is  sharp. 

3.  Small  ovarian  tumour  with  a  long  pedicle. — This  can  be  reduced 
into  the  pelvis,  but  not  into  the  loin  ;  the  pedicle  is  attached  below 
and  can  be  demonstrated  from  the  vagina. 

4.  Malignant  growth  of  the  intestine. 
').  Scybalous  masses  in  the  intestine. 

In  doubtful  cases  an  opaque  catheter  should  be  passed  up  the 
ureter,  the  pelvis  of  the  kidney  filled  with  collargol  (10  per  cent.), 
and  a  radiogram  obtained. 

Treatment. — Operation  is  imperative — (1)  where  the  mobility 
is  causing  disease  of  the  kidney,  (2)  where  the  kidney  is  exerting 
harmful  traction  on  other  organs  ;  (3)  where  the  kidney  lies  below 
the  waist  line  and  is  uncontrolled  by  a  mechanical  apparatus  ;  (4) 
when  the  patient  is  going  to  reside  in  tropical  and  uncivilised 
countries  ;  (5)  where  the  patient  has  to  perform  manual  labour  and 
cannot  afford  an  expensive  apparatus.  But  in  most  cases  palliative 
treatment  may  be  tried  before  resorting  to  operation. 

Operative  treatment  is  likely  to  fail — (1)  where  general  visceroptosis 
is  present ;  (2)  where  there  is  severe  neurasthenia  and  no  symptoms 
can  be  referred  to  the  kidney. 

In  a  few  cases  of  movable  kidney  with  neurasthenia,  control  of 
the  renal  movements  by  a  mechanical  apparatus  will  alleviate  or  cure 
the  neurasthenia,  and  in  these  cases  also  operation  will  be  followed 
by  a  similar  result. 

Palliative  treatment.     1.   By  rest  and   by  increasing  the  body 


MOVABLE    KIDNEY:  TREATMENT 

/a/. — It  is  hoped  to  obtain  an  increased  deposil  of  tal  around  the 
kidney,  bul  this  does  aol  obtain  in  practice.  This  treatment  Ls,  how- 
ever, a  useful  adjunct  to  other  methods.  En  Bevere  cases  the  lull 
Weir-Mitchell  treatmenl  Bhould  be  insisted  upon, 

2.  />'/  mechanical  apparatus. — The  kidney  truss  exerts  pressure 
upwards  and  outwards  by  a  thin  padded  metal  plate  (Ernst).  It 
must  be  applied  lying  down. 

The  kidney  belt  is  an  abdominal  belt  coming  down  over  the  iliac 
and  accurately  moulded  to  the  hips.  The  lower  border  follows 
the  curve  of  the  groin  and  overlaps  the  pubic  bones.  There  is  an 
elastic  inset  on  each  side,  and  perineal  straps  are  attached.  An  oval 
or  horse-shoe-shaped  kidney  pad  is  added.  The  belt  must  be 
applied  when  the  patient  is  lying  down.  It  may  be  fitted  t<»  the 
lower  part  of  a  corset. 

The  corset  for  movable  kidney  (Gallant)  is  accurately  fitted.  Below 
the  waist  it  is  inflexible  and  elastic  ;  above  the  waist  it  permits  free 
play  of  the  trunk. 

Operative  treatment. — The  kidney  is  exposed  by  an  oblique 
lumbar  incision  or  by  a  vertical  incision  along  the  outer  border  of  the 
erector  spinse  muscle.  The  kidney  is  then  fixed — (a)  By  sutures  passing 
through  the  kidney  capsule  or  through  the  kidney  substance,  carried 
through  the  muscles  of  the  abdominal  wall  at  the  upper  edge  of  the 
wound,  and  tied,  (b)  By  stripping  the  capsule  of  the  kidney  (decorti- 
cation), (c)  By  stitching  the  stripped  capsule  to  the  parietes  ;  the 
capsule  may  be  rolled  up  on  the  anterior  or  posterior  surface,  or  split 
into  wedges  or  strips,  (d)  By  partial  stripping  and  by  sutures  through 
the  substance  of  the  kidney,  (e)  By  placing  strips  of  gauze  below  the 
lower  pole  to  promote  granulation  and  cicatrization.  (/)  By  the 
formation  of  a  shelf  of  peritoneum  or  fibrous  capsule  ;  this  may  be 
done  by  stitching  through  the  parietal  peritoneum  and  abdominal 
muscles  below  the  kidney  after  opening  the  peritoneal  cavity  (Bishop), 
or  by  reflecting  a  strip  of  fibrous  capsule  and  stitching  it  below  the 
kidney  without  opening  the  abdomen  (Watson  Cheyne). 

Results. — The  operative  mortality  is  stated  at  1  per  cent.,  but 
it  is  lower  than  this  in  skilled  hands.  In  116  cases  examined  not 
less  than  three  months  after  operation,  Keen  found  that  57*8  per  cent, 
were  cured  and  12-9  per  cent,  improved,  while  in  19-8  per  cent,  the 
operation  had  failed.  Failure  consisted  either  in  recurrence  of  the 
mobility  or  in  persistence  of  the  pain. 

INJURIES    TO    THE    KIDXEY 
1.  Injuries  without  External  Wound 

The  right  side  is  more  often  affected  than  the  left,  and  the  injury  is  rarely 
bilateral. 


796  THK   KIDNEY 

Etiology.— Rupture  of  the  kidney  may  lie  due  to  a  direct  blow,  kick, 
1  squeeze,  or  to  indirect  violence,  as  in  a  fall  from  a  height  on  to  the  buttocks, 
or  in  forcible  acute  flexion  of  the  body,  when  the  kidney  may  be  injured 
by  impact  against  the  12th  rib  or  the  transverse  process  of  a  vertebra. 

Pathology. — There  may  he  tearing  of  the  fatty  capsule  alone,  with 
perirenal  haemorrhage  and  subsequent  formation  of  fibrous  tissue,  or  a  slight 
subcapsular  rupture  of  the  kidney,  with  accumulation  of  blood  beneath 
the  fibrous  capsule,  or  a  laceration  of  both  fibrous  capsule  and  kidney  sub- 
stance which  may  reach  the  renal  pelvis.  The  tears  radiate  transversely 
from  the  hilum,  and  affect  especially  the  anterior  surface  and  lower  pole, 
but  may  be  complete.  Sometimes  the  ureter  or  a  large  branch  of  the  renal 
artery  is  ruptured.     Laceration  of  the  renal  pelvis  or  of  a  calyx  is  common. 

The  peritoneum  may  be  torn,  and  blood  and  urine  poured  into  the  peri- 
toneal cavity.  This  occurs  more  frequently  in  children,  since  the  protective 
layer  of  perinephric  fat  is  not  developed  before  the  tenth  year.  Ribs  may 
be  fractured,  or  the  spinal  column,  pelvic  girdle,  bowel,  liver,  spleen,  bladder, 
or  lungs  injured.  Repair  takes  place  rapidly  in  slight  injuries.  Infection 
and  suppuration  causing:  perinephritic  abscess,  suppurative  nephritis,  pyo- 
nephrosis, and  peritonitis  occur  in  11-8  per  cent,  of  cases. 

Symptoms.— Shock  is  present  in  all  severe  grades  of  rupture.  It  may 
be  delayed  for  some  hours,  so  that  the  patient  may  walk  a  considerable 
distance  after  the  accident,  and  only  collapse  when  he  sees  blood  in  the  urine. 
Pain  radiates  along  the  ureter  and  is  accompanied  by  retraction  of  the  testicle. 
It  is  especially  severe  when  clots  are  passing  along  the  ureter.  There  is  also 
dull,  heavy,  deep-seated  pain,  increased  by  pressure  and  movement.  The 
abdominal  muscles  are  rigidly  contracted.  Soon  after  the  injury,  or  some 
days  later,  a  tumour  due  to  perirenal  effusion  of  blood  appears  in  the  loin. 
It  is  dull  on  percussion  and  tender  on  palpation,  and  may  be  movable  (pseudo- 
hydronephrosis).  It  is  usually  diffuse  and  obscured  by  rigidity  of  the  muscles. 
If  the  swelling  is  clearly  outlined  and  "  ballottement  "  can  be  obtained,  the 
renal  pelvis  has  been  distended  with  blood  and  a  haematonephrosis  formed. 

Haematuria  is  present  in  91 -5  per  cent,  of  cases.  It  is  absent  when  the 
rupture  does  not  penetrate  the  renal  pelvis  or  calyces,  when  the  ureter  is 
plugged  with  clot  or  ruptured  by  the  violence.  Blood  may  be  delayed  for 
some  days.  In  half  the  cases  it  has  disappeared  in  a  week,  but  it  may 
persist  and  appear  intermittently  for  several  weeks  and  may  be  fatal  after 
two  to  three  weeks.  In  copious  bleeding  there  is  clotting  hi  the  bladder  with 
retention  of  urine. 

Secondary  haemorrhage  due  to  suppuration  and  necrosis  of  the  kidney 
occurs.  Temporary  or  persistent  anuria  is  sometimes  observed,  and  is  due 
to  previous  disease  or  atrophy  of  the  uninjured  kidnev. 

Discoloration  of  the  skin  at  the  external  abdominal  ring,  scrotum,  or 
labium  may  appear,  after  a  fortnight  or  tliree  weeks,  as  the  result  of  blood 
tracking  along  the  spermatic  vein.  Intraperitoneal  effusion  of  blood  and 
urine  may  be  detected  in  the  pouch  of  Douglas  on  rectal  examination. 

The  possible  complications  and  sequelae  are— (1)  anuria.  (2) 
intraperitoneal  haemorrhage,  (3)  pseudo-hydronephrcsis,  (4)  retention  of 
urine,  (5)  septic  complications,  (6)  traumatic  hydronephrosis,  (7)  movable 
kidney,  (8)  traumatic  nephritis. 

Course  and  prognosis. — In  favourable  cases  the  urine  clears  in 
a  few  days,  and  the  symptoms  disappear  in  ten  days.  In  severe  cases  the 
immediate  dangers  are  shock  and  haemorrhage,  and  the  remote,  septic 
complications  and  anuria.    The  later  the  onset  and  the  less  acute  the  pro- 


INJURIES  797 

■  >f  the  Beptic  process  the  better  the  prognosis.     Prognosis  Lb  chiefly 
l   by  haemorrhage  and  by  injury  to  other  organs.     Recover}    takes 
plaoe  in  T(»  per  rent,  of  uncomplioate  I 

Treatment.  -  slight  and  moderately  Bevere  uncomplicated  ruptures 
are  treated  bj  efficienl  strapping  oi  the  side  and  a  covering  broad  bandage, 
by  ice-bags  over  and  under  the  loin,  and  by  absolute  reel  in  the  recumbent 
position.  The  food  should  be  fluid.  Calcium  lactate  is  given  in  doses  of 
10-15  gr.  every  four  hours,  for  forty-eight  hours,  and  morphia  administered 
hypodermically.  Shock,  it  no!  profound,  should  nol  be  too  energetically 
I.  lest  bleeding  be  encouraged.  It  there  is  retention  the  bladdei 
should  be  emptied  under  the  most  rigid  aseptic  precautions.  An  evacuat- 
ing cannula  and  l>ull>  maj  be  used  to  empty  the  bladder  of  clot  ;  but  if 
this  measure  is  not  quickly  successful  the  bladder  should  be  opened 
Buprapubically,   the  clots  cleared,  out,  and  a  large  drain  inserted. 

Operation  on  the  kidney  may  be  required  for  -(1)  immediate  Bevere 
haemorrhage,  (2)  delayed  Bevere  haemorrhage,  (3)  suppuration  of  the  injured 
kidney,  (4)  septic  peritonitis,  (5)  hydronephrosis  or  pyonephrosis.  The 
kidney  is  exposed  by  an  oblique  lumbar  incision,  the  clots  are  cleared  away, 
and  a  search  made  for  the  bleeding-point.  Tears  of  the  kidney  are  closed 
with  catgut  sutures,  and  extensive  laceration  and  bruising  by  packing  with 
strips  of  gauze.  A  distended  renal  pelvis  should  be  incised,  the  clots  turned 
out,  and  the  pelvis  packed  with  gauze.  Detached  portions  and  shreds  of 
kidney  tissue  are  removed,  and  primary  nephrectomy  may  be  necessary. 
Rectal  and  intravenous  infusion  of  glucose  solution  (1  per  cent.)  should  be 
given  after  the  operation. 

Suppuration  should  be  treated  by  free  incision  and  drainage,  and  lapar- 
otomy may  be  necessary  for  Beptic  peritonitis.  Persistent  anuria  is  treated 
by  nephrotomy  and  packing  [see  also  p.  783). 

Results. — The  results  have  greatly  improved  in  recent  years  -with 
early  aseptic  operations.  Operative  interference  in  septic  complications 
should  not  be  too  long  delayed.  In  uncomplicated  cases  the  death-rate  is 
18-9  per  cent.  In  cases  treated  expectantly  the  mortality  is  21 '1  per  cent.  ; 
in  conservative  operations.  11*7  per  cent.  :  and  in  nephrectomy.  17-9  per 
cent.  (Riese). 

2.   Injuries   with  External  Wound 

Wounds  of  the  kidney  are  much  less  frequent  than  subcutaneous  injuries. 
The  intestine,  spleen,  liver,  or  pleura  may  also  be  wounded.  The  blood 
Be  by  the  external  wound,  and,  unless  there  is  a  long  sinuous  track,  no 
accumulation  takes  place  around  the  kidney.  The  kidney  may  prolapse 
from  a  large  wound.  Primary  union  is  rare,  prolonged  suppuration  common. 
Urinary  fistula?  occur,  but  seldom  persist. 

Symptoms. — There  is  external  hemorrhage,  and  urine  escapes  through 
the  wound  after  a  few  days  when  the  hemorrhage  is  subsiding.  Haemorrhage 
from  stab  wounds  may  be  severe  and  rapidly  fatal.  In  bullet  wounds  the 
external  hemorrhage  is  seldom  severe,  but  it  may  be  intermittent.  Pain 
is  persistent,  but  does  not  radiate  along  the  ureter.  Occasionally,  tlatus  from 
laceration  of  the  intestine  may  be  passed  from  the  external  wound.  Septic 
complications  occur  on  the  fourth  or  fifth  day,  and  portions  of  clothing  and 
sloughs  may  be  discharged. 

Prognosis. — This  is  comparatively  good,  and  operation  is  frequent  lv 
successful.  Wounds  of  other  organs  increase  the  gravity  of  the  prognosis. 
The  mortality  of  incised  wound-  is  as  low  as  1")  per  cent.  (Albarran),  but 
bullet  wounds  have  a  high  mortality — .">.">  per  cent.  (Kiister). 


798  THE   KIDNEY 

Treatment. — If  the  external  haemorrhage  i-  moderate  and  diminishing, 
it  will  be  sufficient  to  clean  and  drain  the  wound.  A  careful  watch  mu-t  be 
kept  for  recurrent  haemorrhage  and  septic  complications.  If  a  foreign  body 
has  lodged,  or  haemorrhage  is  severe,  the  track  should  be  freely  enlarged, 
and  the  kidney  exposed  and  examined.  In  complicated  cases  exploratory 
laparotomy  is  necessary. 

ANEURYSM  OF  THE  RENAL  ARTERY 

[Only  25  cases  of  this  rare  condition  -were  found  in  the  literature  by  Skillern 
in  1906.  It  is  most  often  caused  by  trauma  in  active  men,  but  may  occur 
spontaneously  in  either  sex  in  association  with  endocarditis  or  arterial 
degeneration.  The  size  varies  from  that  of  a  hazel-nut  to  a  large  swelling 
occupying  the  whole  loin  and  extending  inwards  as  far  as  the  middle  line. 
When  the  aneurysm  is  large,  and  especially  when  a  false  aneurysm  has 
formed,  the  kidney  tissue  is  extensively  destroj'ed  by  pressure,  the  colon 
displaced  forwards  and  inwards,  and  the  liver  or  spleen  pushed  upwards. 

Clinical  features. — A  small  aneurysm  produces  no  symptoms ; 
a  large  one  forms  a  swelling  in  the  kidney  region.  The  tumour  usually 
appears  some  days  or  weeks  after  an  injury,  but  two  or  even  fourteen  years 
may  elapse.  The  swelling  is  smooth,  slightly  movable  or  fixed,  and  does  not 
move  with  respiration ;  it  is  rarely  painful  or  tender.  Hsematuria  is  early, 
and  usually  precedes  the  discovery  of  the  swelling.  Profuse  and  rapidly 
fatal  haemorrhage  follows  rupture  into  the  renal  pelvis  or  peritoneal  cavity. 
Pulsation  has  rarely  been  observed.  Morris  found  a  loud  systolic  bruit 
over  the  tumour  in  one  case. 

Treatment. — The  condition  will  usually  be  diagnosed  during  an 
exploratory  laparotomy.  A  small  opening  in  the  sac  should  be  sufficient 
to  permit  recognition  of  the  laminated  character  of  the  contents.  If  severe 
haemorrhage  takes  place  the  wound  should  be  plugged  with  gauze,  the 
abdomen  opened  in  the  semilunar  line,  and  the  pedicle  of  the  kidney  exposed 
and  ligatured.  The  aneurysmal  sac  and  kidney  are  then  removed.  In  three 
cases  operation  has  been  successful. 

PERINEPHRITIS 

Chronic  perinephritis  leads  to  the  formation  around  the  kidney  of 
a  layer  of  inflammatory  tissue,  either  fibro-sclerotic  or  fibro-lipoma- 
tous,  and  tough  adhesions  are  formed  with  surrounding  structures. 

Some  form  of  chronic  inflammatory  disease  of  the  kidney  is 
invariably  present,  such  as  pyelonephritis,  pyonephrosis,  calculus,  or 
tuberculosis 

In  the  sclerotic  form  the  fatty  capsule  of  the  kidney  is  replaced  by 
a  dense  layer  of  fibrous  tissue,  sometimes  of  cartilaginous  hardness. 
In  the  more  common  fibro-lipomatous  form  the  delicate  perirenal  fat 
is  replaced  by  coarse  nodular  fat  with  a  tough  fibrous  stroma.  The 
fibro-lipomatous  mass  may  develop  principally  around  the  pelvis 
or  at  one  pole. 

The  symptoms  and  treatment  are  merged  in  those  of  the  under- 
lying renal  disease.  The  movements  of  the  kidney  are  not  appreciably 
limited. 


ABSCESS  799 

PERINEPHRITIC    \l><  ESS 

A  perinephritic  abscess  may  occur  at  any  age,  and  may  be  primary 
or  secondary.  Men  are  more  frequently  affected  than  women,  and 
the  rigid  Bide  more  often  than  the  left. 

Etiology.  The  primary  form  may  follow  injury.  .More  fre- 
quently  it  develops  during  the  course  of  typhoid,  scarlatina,  measles, 
ot  pneumonia,  tonsillitis,  carbuncle,  or  even  eczema.  The  secondary 
form  complicates  suppuration  in  some  neighbouring  organ,  such 
the  kidney  (25  per  cent.),  liver,  gall-bladder,  appendix,  pelvic  organs, 
or  vertebras.  Tuberculous  perinephritic  abscess  is  especially  found  in 
tuberculous  disease  of  thr  vertebrse,  and  is  very  rarely  secondary 
to  tuberculosis  of  the  kidney.  Pus  from  an  empyema  or  an  abscess 
of  the  lung  may  track  through  the  costo-lumbar  hiatus  of  the  dia- 
phragm  and  form  a  perinephritic  abscess. 

Bacteriology. — The  bacteria  found,  in  their  order  of  frequency. 
are  Bacillus  coli,  streptococcus,  staphylococcus.  The  gonococcus  and 
juieumococcus  are  rare. 

Pathology. — The  collection  is  usually  unilocular,  but  occasion- 
ally multilocular.  It  is  situated  outside  the  fibrous  capsule,  and 
may  be  inside  or  outside  the  perinephric  fascia.  In  the  former  case 
the  pus  will  spread  along  the  ureter  into  the  bony  pelvis,  while  in 
the  latter  it  will  appear  on  the  surface  of  the  body  over  the  iliac  crest 
or  pass  into  the  iliac  fossa.  Four  varieties  are  distinguished  according 
to  situation : 

1.  Above  the  kidney,  or  subphrenic,  which  is  frequently  connected 
with  intrathoracic  suppuration.  The  kidney  is  pushed  down  and 
may  be  felt  below  the  mass. 

2.  Below  the  kidney,  which  tends  to  pass  downwards  to  the  iliac 
fossa  and  may  rupture  into  and  pass  along  inside  the  psoas  sheath 
and  appear  in  Scarpa's  triangle,  or  pass  into  the  pelvis  and  escape 
at  the  sciatic  notch. 

3.  In  front  of  the  kidney,  limited  by  peritoneum  ;  this  is  rare. 
It  may  rupture  into  the  peritoneal  cavity,  bowel,  bladder,  or  vagina. 

4.  Behind  the  kidney,  a  much  more  common  variety  which  may 
pass  through  the  lumbar  muscles  at  the  triangle  of  Petit. 

Symptoms. — When  perinephritic  abscess  complicates  some  other 
disease  the  symptoms  are  superadded  to  those  of  the  primary  disease. 
When  the  perinephritic  suppuration  is  primary  the  onset  is  usually 
insidious  and  the  pain  slight  and  insignificant.  The  general  condi- 
tion of  the  patient  is  bad,  and  there  is  high  remittent  fever,  though 
in  rare  cases  the  temperature  is  not  raised.  Occasionally  the  onset 
is  sudden  and  heralded  by  a  rigor.  Pain  and  tenderness  over  the 
kidney  become  marked.  The  pain  may  radiate  to  the  shoulder  or  arm, 
but  more  frequently  passes  downwards  to  the  scrotum  or  labium.     It 


soo  thp:  kidney 

is  increased  by  movement,  respiration,  coughing  and  sneezing.  The 
abdominal  muscles  are  rigid  on  the  diseased  side. 

The  corresponding  thigh  is  stiff  and  becomes  flexed  and  rotated 
slightly  outwards.  Extension  is  restricted,  but  flexion  unlimited. 
There  may  be  transient  paralysis  of  the  lower  limb. 

The  whole  loin  bulges  outwards  and  backwards.  The  anterior 
swelling  is  less  than  in  kidney  tumours.  The  tumour  does  not  move 
on  respiration,  and  there  is  little  movement  on  palpation.  In  supra- 
renal perinephritic  abscess  there  may  be  jaundice,  ascites,  and  cedema 
of  the  legs,  and  persistent  vomiting  when  the  right  side  is  affected. 
In  infrarenal  abscess  there  are  symptoms  of  involvement  of  the 
psoas  muscle,  neuralgic  pain  in  the  groin  and  genitals,  retraction  of 
the  testicle,  and  constipation.  (Edema  in  the  loin  may  be  present, 
especially  if  the  abscess  be  behind  the  kidney.  When  the  kidney  is 
diseased  there  is  pyuria.  In  acute  cases,  pus  forms  in  from  ten  to 
twelve  days  ;  in  subacute,  in  three  or  four  weeks. 

In  tuberculous  cases  acute  symptoms  are  absent,  and  pain  and 
tenderness  are  slight. 

If  no  operation  is  performed,  either  the  patient  dies  of  septicaemia 
or  the  abscess  ruptures  on  the  surface  or  into  the  pleura,  bronchi, 
colon,  peritoneum,  bladder,  or  vagina. 

Diagnosis. — The  condition  may  be  mistaken  for  typhoid  fever 
in  the  early  stage,  and  for  hip-joint  disease  or  pyonephrosis  at  a  later 
period.  When  only  fever  and  general  symptoms  are  present,  leuco- 
cytosis  will  show  that  suppuration  is  going  on  in  the  body,  a  negative 
Widal  reaction  will  exclude  typhoid  fever,  and  examination  of  the 
blood  will  eliminate  malaria.  Against  hip-joint  disease  there  are  freedom 
of  flexion  and  rotation  of  the  thigh  and  absence  of  local  tenderness. 

A  pyonephrosis  is  regular  and  well  defined;  it  moves  with  respira- 
tion, projects  forwards  rather  than  laterally  or  backwards,  and  does 
not  cause  cedema  of  the  skin.  A  pyonephrosis  may  be  present  and 
be  concealed  by  a  perinephritic  abscess. 

Prognosis. — Good  results  are  obtained  by  prompt  operation 
in  primary  cases.  The  longer  the  operation  is  delayed  the  worse  is 
the  prognosis.  In  secondary  perinephritic  abscess  the  prognosis 
depends  upon  the  original  cause. 

Treatment. — Early  operation  is  the  only  successful  method. 
The  kidney  is  exposed  by  an  oblique  incision,  and  all  pockets  of  the 
abscess  drained,  care  being  taken  not  to  overlook  iliac  and  subphrenic 
collections  of  pus. 

If  the  kidney  is  the  seat  of  abscess,  pyelonephritis-,  or  pyo- 
nephrosis, it  should  he  freely  incised  and  drained.  If  nephrectomy  be 
necessary  it  should  be  postponed  to  a  later  date.  When  the  abscess 
has  originated  in  an  empyema,  this  should  be  drained. 


PYELONEPHRITIS  80 1 

In   Old-Standing    cases    with    persistent    sinuses    a,    diseased     kidnev 

or  an  imperfectly  drained  empyema  may  necessitate  nephrectomy, 
resection  of  portions  of  ribs,  or  other  secondary  operations. 

The  mortality  of  cases  treated  witliuut  operation  is  80  per  cent.. 

and  of  operated   cases   7-1    pel  cent.   (Watson). 

SURGICAL  [NFLAMMATIONS  OF  THE  KIDNEY  AND  PELVIS 

These  may  lie  bacterial  or  nonbacterial,  and  caused  by  mechanical 
aeans  or  by  the  excretion  of  irritants, 

Aseptic  Pyelonephritis 
This  form  of  pyelonephritis  occurs  under  the  following  conditions  : — 

1.  In  acute  retention  of  urine. — Guyon  and  Albarran  have  shown 
that  in  retention  of  urine  there  may  be  acute  congestion  of  both  kidneys, 
progressing  to  interstitial  and  intratubular  haemorrhages  with  desqua- 
mation of  tubular  epithelium.  The  quantities  of  urine  and  of  renal 
salts  are  reduced,  and  blood,  renal  cells,  and  epithelial  and  blood 
casts  are  present.  Polyuria  follows  relief  of  the  retention,  and  the 
urine  contains  casts  for  several  days.  If  the  obstruction  is  completely 
relieved  and  sepsis  is  absent,  the  symptoms  entirely  disappear. 

2.  Due  to  excretion  of  irritants. — A  mild  catarrhal  pyelonephritis 
may  be  induced  by  the  elimination  of  certain  balsamics,  such  as 
sandalwood,  copaiba,  and  turpentine. 

3.  In  chronic  urinary  obstruction. — In  this  condition  the  ureters 
and  renal  pelvis  become  dilated  and  thickened,  and  chronic  interstitial 
nephritis  develops.     Both  kidneys  are  affected,  but  usually  unequally. 

The  symptoms  are  slight  and  easily  overlooked.  Dull  aching  pain 
in  one  or  both  kidneys,  constant  thirst,  especially  at  night,  and  anorexia 
are  associated  with  frontal  headache  and  appreciable  loss  of  weight. 
The  temperature  is  slightly  subnormal,  and  the  tongue  dry.  There 
are  no  cardiac  or  vascular  changes  ;  the  kidneys  cannot  be  felt  and 
are  not  tender. 

The  urine  is  pale  and  clear,  free  from  tube  casts  and  cells,  and 
contains  a  low  percentage  of  urea  and  other  urinary  constituents. 
The  polyuria  amounts  to  SO-100  ounces  per  diem,  and  is  more 
marked  at  night. 

Infections  of  the  Kidney  and  Pelvis 

Bacteriology. — The  Bacillus  coli  is  the  commonest  cause  of 
renal  infection  ;  next  in  frequency  come  the  staphylococci  (especially 
aureus),  streptococci,  Proteus  vulgaris  (Hauser),  and  B.  pyocyaneus  ; 
the  pneumococcus  and  the  gonococcus  are  rare.  The  B.  coli  is  usually 
found  in  pure  culture,  but  sometimes  is  mixed  with  proteus,  staphy- 
lococcus, or  streptococcus.  Anaerobic  bacteria  are  occasionally  found. 
'2z 


So2  THE   KIDNEY 

especially  in  pyonephrosis.  The  staphylococcus  and  Proteus  vulgaris 
cause  ammoniacal  decomposition  ;  in  the  rare  pure  streptococcal  and 
in  the  common  B.  coli  infections  the  urine  remains  acid. 

Pyelonephritis  occurs  in  two  forms — (a)  primary  or  "  haemato- 
genous"  pyelonephritis,  appearing  without  previous  urinary  disease, 
and  believed  to  be  caused  by  blood-borne  bacteria  ;  and  (b)  secondary 
or  "  ascending  "  pyelonephritis,  which  follows  infection  of  the  lower 
urinary  tract. 

(a)  Primary  or  hematogenous  pyelonephritis.  —  This 
disease  occurs  in  infants,  children,  and  adults.  In  infants  and 
young  children  it  is  comparatively  common,  and  affects  the  pelvis 
more  severely  than  the  kidney.  In  adults  it  exhibits  a  predilection 
for  the  right  kidney,  for  the  most  active  period  of  life,  and  for  the 
female  sex,  especially  during  pregnancy  (see  p.  808). 

Etiology. — Usually  there  is  a  history  of  chronic  constipation, 
and  sometimes  of  recent  diarrhoea  ;  in  such  cases  the  colon  is  probably 
the  chief  source  of  the  bacteria.  Tonsillitis,  boils,  or  carbuncles 
may  be  the  primary  focus,  while  the  renal  infection  occasionally 
complicates  influenza  or  typhoid  fever. 

(b)  Secondary  or  ascending  pyelonephritis. — This  dis- 
ease results  from  extension  of  infection  from  the  lower  urinary  organs. 
It  is  the  last  phase  of  many  chronic  vesical  and  urethral  diseases,  and 
sometimes  follows  surgical  interference  with  the  bladder  or  urethra 
("surgical  kidney'").  Although  at  first  often  unilateral,  later  it  is 
invariably  bilateral,  affecting  one  side  more  than  the  other.  As 
seen  by  the  surgeon,  the  disease  is  bilateral  in  83  per  cent,  of  cases. 

Etiology. — Bacteria  are  introduced  into  the  bladder  by  faulty 
instrumentation,  or  rarely  are  carried  from  a  previously  infected 
urethra  by  a  sterile  instrument.  The  predisposing  causes  are  urethral 
obstruction,  prolonged  cystitis,  vesical  new  growths,  operations  on 
the  bladder  involving  the  ureteric  orifice,  and  stone  in  the  bladder  or 
ureter. 

Pathology  of  infective  pyelonephritis. — In  the  acute 
forms  there  may  be  extensive  haemorrhages  in  the  renal  substance, 
with  irregular  pale  or  yellowish  purulent  areas  in  the  cortex  and 
medulla.  Sometimes  small  bosses  on  the  surface  correspond  to  the 
position  of  these  areas.  Microscopically,  definite  abscesses  are  seen, 
with  destruction  of  kidney  tissue,  and  cloudy  swelling  of  the  secre- 
tory epithelium  is  a  prominent  feature.  There  are  patches  of  dense 
infiltration  with  leucocyte-. 

In  the  most  fulminating  types  the  kidney  is  plum-coloured,  with 
dark  cortex  and  paler  pyramidSj   and  is  engorged  with  blood. 

In  the  chronic  varieties  the  abscesses  may  be  still  present,  but  there 
is  always  marked  interstitial  change,  and  at  points  collections  of  small 


INFECTIVE   PYELONEPHRITIS  803 

round  lymphocyte-like  cells  are  .seen.  At  places  1 1 1« ■  tubules  and 
glomeruli  may  be  destroyed  by  the  newly  formed  fibrous  tissue.  In 
very  advanced  cases  the  kidney  may  be  much  reduced  in  size,  very 
tough,  and  firmly  adherent  to  the  surrounding  tissues.  Ii  may  con- 
tain small  cyst-. 

Clinical  features.  (1)  Acute  haematogenous  pyelone- 
phritis.- The  at  lack  is  often  preceded  by  headache,  lassitude,  and 
anorexia,  and  by  diarrhiea  or  by  an  exaggeration  of  habitual  con- 
stipation. In  (i  per  cent,  of  cases  there  is  a  sudden  desire  to 
micturate,  followed  by  great  frequency  and  strangury  lasting  a  few 
hours  or  a  day  or  two. 

In  a  mild  case  there  is  a  rigor  followed  by  rise  of  temperature  to 
101°  or  102°,  aching  in  one  loin,  and  tenderness,  without  enlargement, 
of  one  kidney.  The  urine  is  abundant,  pale,  with  low  specific  gravity 
and  a  stale-fish  odour,  and  bacteruria  is  present.  The  attack  lasts 
ten  or  fourteen  days. 

In  a  more  severe  attack  the  temperature  reaches  102°  or  103°, 
the  patient  is  prostrate,  drowsy,  perhaps  delirious,  and  suffers  general 
abdominal  pain,  and  also  backache,  especially  in  one  loin.  The 
diseased  kidney,  which,  as  a  rule,  is  palpably  enlarged,  is  intensely 
tender,  and  the  abdominal  muscles  on  that  side  are  rigid.  The  urine 
is  scanty,  acid  (very  rarely  alkaline),  and  contains  bacteria,  pus  cells, 
blood  corpuscles,  tube  casts,  and  epitiielia  from  the  renal  pelvis  and 
bladder.  The  leucocyte  count  is  18,000 "to  20,000.  The  Bacillus  coli 
has  been  found  in  the  blood,  especially  in  children. 

After  two  or  three  weeks  the  acute  symptoms  may  subside,  but 
may  repeatedly  recur  owing  to  exacerbations  in  the  first  kidney  or 
to  fresh  infection  of  the  second  kidney. 

The  illness  may  last  for  months.  Instead  of  pursuing  a  benign 
course,  there  may  be  repeated  rigors,  a  high  swinging  temperature 
(103°  to  107°),  and  death  occurs  in  four  or  six  weeks  from  the  onset. 

In  the  rare  fulminating  cases  a  severe  rigor  and  rise  of  tempera- 
ture to  104°  or  106°  is  followed  by  drowsiness  and  coma.  *  There 
are  abdominal  pain  and  rigidity,  vomiting,  and  scantiness  or  com- 
plete suppression  of  urine. 

(2)  Acute  ascending  pyelonephritis. — During  the  course  of 
some  disease  of  the  lower  urinary  organs,  and  usually  as  a  sequel 
to  instrumentation,  there  is  a  rigor  with  a  rise  of  temperature  to  102° 
or  104°.  Drowsiness,  apathy,  and  backache,  more  marked  on  one 
side,  are  frequently  associated  with  nausea,  vomiting,  absolute  con- 
stipation, and  increasingly  distressing  hiccup.  The  tongue  is  dry, 
red,  and  glazed,  and  later  becomes  covered  with  brown  or  black 
fur  ("parrot  tongue  ").  The  abdomen  shows  flatulent  distension  and 
rigidity,   especially  on  one  side.     At  first  both  kidneys  are  tender, 


8o4  THE   KIDNEY 

but  after  twenty-four  hours  this  is  confined  to  one  organ,  which  is 
enlarged.  Polyuria  has  frequently  been  present  beforehand,  but 
now  is  replaced  by  partial  or  complete  suppression.  The  tempera- 
ture may  remain  at  102°  or  over,  or  may  be  high  and  swinging 
with  recurring  rigors.     Labial  herpes  is  common. 

The  symptoms  increase  in  severity,  muttering  delirium  supervenes, 
and  the  patient  becomes  comatose  and  dies.  Uraemic  dyspnoea  and 
Cheyne-Stokes  breathing  may  be  present,  but  convulsions  are  ex- 
tremely rare.  In  less  severe  cases  the  secretion  of  urine  becomes 
re-established,  the  temperature  falls,  flatus  is  passed,  and  the  symp- 
toms subside. 

Some  cases  are  characterized  by  recurrent  haemorrhages. 

(3)  Chronic  suppurative  pyelonephritis. — Chronic  pyelone- 
phritis may  follow  acute  pyelonephritis,  whether  haematogenous  or 
ascending,  or  may  be  engrafted  on  a  chronic  aseptic  pyelonephritis  ; 
when  fully  developed  it  gives  rise  to  "  urinary  septicaemia."  The 
complexion  is  sallow,  the  skin  dry  and  harsh,  the  mouth  and  throat 
dry,  the  tongue  dry,  and  later  glazed,  red,  and  cracked.  There  are 
dyspepsia,  nausea,  frontal  headache,  and  constant  drowsiness,  with 
persistent  loss  of  weight  and  appetite. 

The  urine  is  abundant  (80-100  oz.  per  diem),  pale,  neutral  or  faintly 
acid,  of  sp.  gr.  about  1006,  and  hazy  with  pus  or  with  flakes.  Bacteria 
are  plentiful,  but  bacteriuria  only  occasionally  occurs.  Nocturnal 
polyuria  and  vesical  irritation  are  the  chief  subjects  of  complaint. 
In  the  ascending  variety  the  symptoms  of  the  primary  lower  disease  are 
also  present.  Acute  exacerbations  are  probable  from  time  to  time, 
■especially  after  surgical  intervention. 

Prognosis. — (1)  In  mild  cases  of  haematogenous  pyelonephritis 
the  prognosis  is  good,  but  relapses  may  occur,  and  in  a  large  per- 
centage of  cases  bacteriuria  or  slight  chronic  pyelonephritis  persists. 
In  acute  cases  the  outlook  is  grave,  and  operation  is  frequently 
necessary.     Fulminating  cases  frequently  terminate  fatally. 

(2)  Many  patients  die  during  the  acute  attack  of  ascending 
pyelonephritis,  and  most  of  those  that  recover  suffer  from  chronic 
pyelonephritis.  Removal  of  the  urinary  obstruction  will  probably 
arrest  the  disease,  but  the  kidneys  are  permanently  damaged. 

(3)  Chronic  pyelonephritis  persists  for  years,  and  eventually 
destroys  the  kidney.  The  dangers  of  secondary  stone  formation  in 
the  kidney  and  of  ascending  pyelonephritis  in  the  other  kidney  are 
ever  present. 

Treatment.  (1)  Acute  haematogenous  pyelonephritis. 
(a)  Medicinal. — Mild  and  early  cases  may  be  suitably  treated  by  con- 
finement to  bed,  and  the  application  of  cupping  or  of  hot  fomentations 
and  turpentine  stupes  over  the  loins,  combined  with  the  administration 


PYELONEPHRITIS:    TREATMENT  805 

of  urinary  antiseptics  such  as  urotropine,  hetraline,  or  helmitol,  and 
the  free  use  of  alkalis  and  diuretics  such  as  theocin  sodium  acetate, 
potassium  citrate,  and  Contrexeville  water.  A  smart  purge,  followed 
by  small  doses  (._.'„  to  £  gr.)  of  calomel,  should  be  given. 

(b)  Scrum  treatment. — The  suitable  anti-serum,  usually  the  anti- 
bacillus  coli  serum,  may  be  hypodermically  injected  in  daily  doses  of 
25  c.c.  for  three  days,  accompanied  by  calcium  lactate  in  20-gr.  doses 
thrice  daily  by  the  mouth  to  prevent  joint  pains  and  serum  rashes. 
This  treatment  is  only  suitable  for  acute  cases,  and  should  be  abandoned 
if  not  effectual  in  three  days. 

(c)  Vaccine  treatment. — Graduated  doses  of  dead  bacteria  are  injected 
from  autogenous  cultures,  or  from  stock  vaccine  if  time  prevents 
the  preparation  of  an  autovaccine.  Beginning  with  small  doses  of 
2  or  3  millions,  repeated  in  four  or  five  days,  the  dose  rises  rapidly  to 
10,  15,  20,  25,  30  millions,  and  so  on  to  100,  150,  and  200.  These 
injections  should  be  made  once  a  week ;  if  any  reaction  occurs,  the 
doses  should  be  reduced  and  a  longer  interval  allowed.  This  treat- 
ment is  only  suitable  for  chronic  cases  where  no  complication  such  as 
growth  or  stone  is  present. 

(d)  Operative  treatment. — Only  nephrotomy  and  nephrectomy  need 
be  considered.  I  have  collected  20  cases  of  nephrotomy  with  7  deaths  ; 
these  include  5  personal  cases,  all  of  whom  survived  nephrotomy. 
The  after-results  of  nephrotomy  are  unsatisfactory ;  chronic  pyelo- 
nephritis persists,  and  nephrectomy  may  be  required  later.  Nephrec- 
tomy gives  the  best  results  in  acute  cases  ;  of  17  collected  cases,  all 
recovered.    ■ 

(2)  Acute  ascending  pyelonephritis. — (a)  Prophylactic  mea- 
sures consist  in  rigid  asepsis  and  the  utmost  gentleness  in  all  urethral 
manipulations. 

(b)  Non-operative  treatment  is  conducted  on  the  lines  laid  down 
for  acute  hematogenous  pyelonephritis  (above).  Sweating  may  be 
induced  by  a  hot  pack  or  hot  vapour  bath,  and  by  hypodermic  injection 
of  pilocarpine.  Suppression  of  urine  demands  rectal  or  intravenous 
infusion  of  glucose  solution  (see  Anuria,  p.  783). 

(c)  Operative  treatment. — This  is  necessary  if  non-operative  measures 
fail ;  it  aims  at  two  objects — removal  of  urinary  obstruction  if  present, 
and  relief  of  congestion  and  drainage  of  the  kidney.  Any  unre- 
lieved urinary  obstruction  first  receives  attention.  Suprapubic  cyst- 
otomy rapidly  performed,  and  the  insertion  of  a  large  tube,  gives  the 
best  drainage  with  the  least  shock.  The  obstruction  can  be  more 
permanently  treated  later  if  the  patient  survive.  For  relief  of  the 
renal  congestion  and  sepsis,  the  kidney  should  be  freely  incised  along 
the  convex  border  and  a  large  rubber  drain  introduced  into  its 
pelvis  ;    another  large  drain  is  placed  outside  the  kidney. 


So6  THE   KIDNEY 

Nephrectomy  may  become  necessary  in  the  hemorrhagic  type  of 
pyelonephritis. 

(3)  Chronic  pyelonephritis. — Prophylaxis  consists  in  all  mea- 
sures directed  against  chronic  obstruction  and  sepsis  in  the  lower 
urinary  organs. 

When  chronic  pyelonephritis  has  become  established,  operative 
interference  with  bladder  or  urethra  must  be  undertaken  with  the 
utmost  caution.  Suprapubic  drainage  should  precede  prostatectomy 
by  a  week  or  more,  and  external  urethrotomy  should  be  preferred  to 
dilatation  or  internal  urethrotomy  for  stricture.  Urinary  antiseptics 
and  diuretics  should  be  freely  administered. 

If  the  second  kidney  is  proved  to  be  healthy  by  examination  of 
its  urine,  nephrectomy  may  be  performed.  Circumstances,  however, 
rarely  render  this  possible. 

In  chronic  hematogenous  pyelonephritis  operation  may  be  necessary 
for  recurrent  exacerbations,  persistent  cystitis,  secondary  calculus,  or, 
rarely,  anuria. 

Vaccine  treatment,  at  any  rate  in  cases  complicated  by  stone, 
growth,  or  obstruction,  has  not  given  satisfactory  results. 

PYELITIS 

The  intimate  relation  between  the  kidney  and  the  renal  pelvis 
precludes  absolute  limitation  of  severe  inflammation  to  one  or  other, 
but  there  are  cases  of  mild  subacute  or  chronic  inflammation  where 
the  pelvis  is  affected  and  the  kidney  but  slightly  involved. 

Etiology. — Mid  adult  life  is  most  frequently  affected.  The 
infection  may  be  hematogenous,  or  may  ascend  from  the  lower  urinary 
organs.     A  calculus  may  be  present  in  the  renal  pelvis. 

Pathology. — The  mucous  membrane  is  hypergemic,  and  in 
severe  forms  is  thickened,  velvety,  and  may  show  petechia?  and  super- 
ficial ulceration.  In  old-standing  pyelitis  the  wall  is  thick  and  leathery, 
the  mucous  membrane  is  opaque  and  may  show  small  colloid-filled 
cysts  (pyelitis  cystica)  or  tiny  sago-grain  lyniph-follicles  (pyelitis 
granulosa).     The  condition  may  be  unilateral  or  bilateral. 

Symptoms. — These  are  usually  insignificant  in  non-calculous 
pyelitis.  The  temperature  may  rise  to  100°  F.  at  night,  and  there 
is  slight  constant  renal  aching  with  occasionally  some  tenderness  on 
pressure.     The  kidney  is  not  enlarged. 

Po^nrria  is  present,  most  markedly  at  night.  The  urine  is  pale, 
opalescent,  acid,  of  low  specific  gravity  (1008),  and  usually  odourless, 
but  occasionally  it  has  a  fishy  smell.  On  standing,  it  deposits  a  flat 
creamy  layer  of  pus  which  moves  heavily  on  tilting  the  glass.  Micro- 
scopically, bacteria  and  tailed  and  overlapping  epithelial  cells  are  seen, 
but  no  tube  casts. 


PI  I  LITIS  807 

Cystoscopically  the  ureteric  efflux  is  copious,  frequently  repeated, 
and  cloudy.  The  lips  of  the  ureteric  orifice  are  reddened  and  thick 
and  Burrounded  by  a  halo  of  congestion.  Urethral  catheterization 
demonstrates  the  characteristic  urine,  which  may  be  alkaline  on  the 
diseased  side. 

The  symptoms  of  pyelitis  may  be  obscured  by  those  of  cyBtitis. 

Diagnosis.  In  cystitis  the  diagnosis  depends  upon  the  presence 
of  renal  aching,  the  observation  of  a  cloudy  efflux  and  changes  at 
the  ureteric  orifice,  and  the  examination  of  a  specimen  drawn  by  the 
ureteric  catheter.  It  is  incomplete  until  calculus  has  been  found  or 
excluded. 

Treatment. — Any  cause  of  local  irritation  such  as  -tone  >hould 
be  removed,  and  diseases  of  the  lower  urinary  tract  such  as  stricture 
and  enlarged  prostate  treated. 

Urinary  antiseptics  (urotropine,  hetralin,  helmitol)  and  diuretic 
waters  (Contrexeville,  Evian,  Vittel)  should  be  given. 

Vaccine  treatment  should  be  tried  in  chronic  cases  (see  Pyelo- 
nephritis, p.  805). 

Instillations  of  argyrol  and  other  silver  preparations  may  be 
•made  through  the  ureteric  catheter,  but  are  only  justifiable  in  expert 
hands. 

In  severe  cases,  where  all  methods  of  treatment  have  failed,  the 
kidney  should  be  exposed,  the  pelvis  opened,  drained  by  a  rubber 
tube  and  washed  with  nitrate  of  silver  solution. 

Pyelitis  of  Infancy  and  Childhood 

Many  cases  are  met  with  in  infants  and  older  children,  especially 
girls.  There  is  frequently  a  history  of  constipation,  and  sometimes 
of  diarrhoea. 

The  symptoms  begin  suddenly  with  a  rigor,  followed  by  rise 
of  temperature  (1043  to  100°  F.),  which  becomes  remittent  in  type. 
The  child  is  pale,  restless,  and  distressed.  Anorexia  is  marked,  and 
delirium,  squinting,  and  vomiting  follow.  Emaciation  is  slow.  There 
may  be  repeated  chills. 

The  local  symptoms  are  insignificant.  Attacks  of  screaming  due 
to  colic  occur,  and  there  mav  be  tenderness  on  palpation  of  the  kidney. 
There  is  occasionally  pain  during  and  increased  frequency  of  micturition. 
Yellowish  staining  of  the  diapers  may  be  the  first  sign. 

The  urine  is  strongly  acid  and  contains  pus,  some  albumin,  red 
blood-corpuscles,  epithelial  cells  from  the  renal  pelvis  and  sometimes 
from  the  bladder,  and  occasionally  hyaline  and  finely  granular  casts. 
Bacteria  are  present,  usually  the  Bacillus  coli,  occasionally  the  staphy- 
lococcus or  the  streptococcus. 

Diagnosis. — This  depends  upon  the  examination  of  the  urine. 


808  THE   KIDNEY 

Pyrexia  with  extreme  distress  and  rigors  without  other  symptoms  in 
a  child  under  two  years  where  malaria  can  be  excluded  are  usually 
due  to  pyelitis  (J.  Thomson). 

The  condition  has  been  mistaken  for  malaria,  typhoid,  and  general 
tuberculosis. 

Prognosis.— Kapid  improvement  under  treatment  and  recovery 
is  the  rule,  but  a  fatal  termination  occasionally  occurs. 

Treatment. — Citrate  of  potash  is  given  in  doses  of  24  gr.,  or 
in  severe  cases  36-48  gr.,  per  day,  in  infusion  of  digitalis,  and  continued 
till  the  danger  of  relapse  is  past ;  urotropine  and  salol  may  be  added. 

Operative  measures  are  rarely  necessary.  Nephrotomy  may  be 
performed  if  the  child  is  steadily  losing  ground. 

Pyelitis  (Pyelonephritis)  of  Pregnancy 

Pyelonephritis  not  infrequently  develops  during  pregnancy,  when 
it  has  special  characteristics. 

Pathology. — The  bacteriology  is  similar  to  that  of  other  renal 
infections.  The  right  kidney  is  nearly  always  attacked  (93  per  cent.), 
and  the  disease  most  frequently  appears  about  the  fourth  month  of 
pregnancy.  It  has  been  ascribed  to  compression  of  the  ureter  by  the- 
gravid  uterus,  but  at  this  early  stage  the  uterus  is  hardly  likely  to 
cause  pressure.  The  infection  may  have  followed  the  passage  of  a 
catheter  (ascending),  or  may  be  heematogenous. 

Symptoms. — There  is  a  rigor  and  the  temperature  rises,  with 
severe  paroxysmal  unilateral  renal  pain  and  frequent  painful  mic- 
turition. The  urine  contains  pus  and  bacteria,  but  may  be  almost 
clear  even  in  severe  cases.  The  general  condition  usually  remains 
good,  although  the  temperature  is  high  and  swinging.  In  a  few  cases 
the  disease  is  bilateral,  and  there  are  rapid  emaciation,  drowsiness,, 
burning  thirst,  dry  tongue,  and  other  signs  of  uraemia.  The  abdomen 
is  rigid  on  one  side,  and  the  kidney  tender  and  enlarged. 

Diagnosis. — This  depends  on  the  position  of  the  pain  and 
tenderness,  and  on  the  examination  of  the  urine.  A  mistaken  diagnosis 
of  appendicitis  may  easily  be  made. 

Prognosis. — Premature  labour  occurs  in  25  per  cent,  of  cases, 
and  the  child  dies  in  one-third  of  these  (Legueu).  When  the  attack 
occurs  early  in  pregnancy  the  puerperium  is  usually  apyretic,  but  if 
the  onset  is  late  there  is  usually  fever  dining  the  puerperium.  If 
the  pyelitis  is  late  and  the  pregnancy  goes  on  to  full  term  the  child  is 
healthy  and  well  nourished. 

Bacilluria  and  slight  pyelonephritis  frequently  persist,  and  there 
are  exacerbations  during  succeeding  pregnancies. 

Treatment. — Prophylaxis  consists  in  careful  asepsis  in  catheter- 
ization, and  in  the  treatment  of  constipation  during  pregnancy. 


PYONEPHROSIS  S09 

If  bacilluria  or  chronic  pyelonephritis  is  present,  this  should  be 

energetically  treated.  The  production  of  abortion  <>r  the  induction 
of  premature  labour  is  seldom  necessary,  but  may  be  called  for  in 
a  severe  case.  Urinary  antiseptics  and  vaccine  treatment  should  be 
given.  Nephrotomy  has  yielded  good  results  in  severe  cases.  In  acute 
bilateral  pyelonephritis,  premature  labour  should  be  induced. 

Nephrectomy  may  be  necessary  in  grave  unilateral  pyelonephritis. 
It  is  well  borne  in  the  early  months  of  pregnancy,  but  less  so  after 
the  fifth  month.     The  mortality  is  9-5  per  cent.  (Cova). 

PYONEPHROSIS 

Pyonephrosis  is  distension  of  the  kidney  and  its  pelvis  with  pus 
or  purulent  urine.  There  are  two  forms — (1)  pyonephrosis  secondary 
to  hydronephrosis,  or  uro-pyonephrosis  ;  (2)  pyonephrosis  from  acute 
pyelonephritis. 

Etiology. — The  etiology  of  uro-pyonephrosis  is  similar  to  that 
of  hydronephrosis.  The  condition  is  unilateral,  most  frequent  on 
the  right  side  and  in  women.  The  obstruction  is  usually  situated 
high  in  the  ureter  and  is  due  to  stone,  stricture,  or  ureteral  duplication. 
The  superadded  infection  is  either  ascending,  from  recent  cystitis,  or 
haematogenous. 

Pyonephrosis  developing  in  acute  pyelonephritis  may  complicate 
chronic  disease  of  the  lower  urinary  organs,  and  is  more  frequent  in 
men. 

The  bacteria  are  those  of  other  renal  infections.  A  pyonephrosis 
is  "  open  "  when  the  obstruction  is  incomplete,  and  "  closed  "  when  it 
is  complete. 

Pathology. — When  the  infection  ascends,  the  pelvis  is  greatly 
dilated.  In  other  cases  the  kidney  is  transformed  into  a  large  multi- 
locular  sac,  and  the  pelvis  is  small  and  hidden.  The  kidney  is 
frequently  firmly  adherent  to  its  surroundings,  and  may  be  sur- 
rounded by  a  thick  .fibro-fatty  layer.  The  interior  is  lined  with 
smooth,  tough,  thick  membrane,  and  the  wall  contains  sclerosed 
and  infiltrated  renal  parenchyma. 

Partial  pyonephrosis  may  occur  from  blocking  of  one  section  of  a 
dichotomous  pelvis  or  of  one  or  several  calyces  by  stone.  In  uro- 
pyonephrosis  the  contents  are  urine  with  a  varying  admixture  of  pus. 
In  pyonephrosis  there  is  pus  with  little  urine.  Primary  or  secondary 
calculi  may  be  present.  (Fig.  538.)  The  ureter  is  dilated,  thickened, 
and  tortuous  when  the  obstruction  is  low  down. 

Clinical  features. — The  symptoms  of  cystitis  may  obscure 
those  of  pyonephrosis.  In  the  ascending  variety  there  are  usually 
symptoms  of  pyelonephritis.  Suppuration  in  a  hydronephrosis  is 
shown  by  a  rigor  and  a  rise  in  temperature. 


Sio 


THE   KIDNEY 


The  symptoms  of  pyonephrosis  are  pain,  tenderness,  swelling,  and 
pyuria.  The  pain  is  constant,  heavy  and  boring  in  character,  and 
tenderness  is  pronounced  at  first.  There  may  be  severe  colic  and 
also  flexion  of  the  thigh.  The  tumour  has  the  characteristics  of  a 
renal   tumour,  and  is  large,  firm,  smooth,  and  non-fluctuating. 

Pyuria  is  the 
cardinal  symptom. 
It  forms  an  abun- 
dant thick,  heavy 
deposit,  subject  to 
pronounced  varia- 
tions in  quantity. 
There  are  recurrent 
attacks  of  complete 
retention  of  pus, 
during  which  the 
urine  becomes 
clear,  the  tumour 
larger,  more  tender, 
painful  and  tense, 
and  the  tempera- 
ture rises. 

On  cystoscopy, 
cystitis  is  usually 
found,  and  the  ori 
fice  of  the  ureter 
is  seen  to  be  open, 
round,  and  immo- 
bile, and  to  have 
thick  and  in  some 
instances  cedema- 
tous  or  ulcerated 
margins. 

In  a  closed  pyo- 
nephrosis an  efflux 
is    absent ;    in    an 
open    pyonephrosis 
it  consists  of  semi-solid  pus,   watery  pus,  or  purulent  urine. 

Diagnosis. — The  diagnosis  of  a  closed  pyonephrosis  depends 
upon  the  history  of  pyuria,  and  the  presence  of  a  renal  tumour  with 
symptoms  of  septic  absorption. 

If  pyuria  is  present,  this  and  cystoscopy  will  lead  to  a  diagnosis. 
Large  intermittent  discharges  of  pus  in  the  urine  are  found  in  three 
conditions,    viz.    pyonephrosis,    a    suppurating    vesical    diverticulum 


Fig.    538. — Calculous   pyonephrosis   with 
dilatation  of  ureter. 


PYONEPHROSIS  811 

and  a  purulenl  collection  communicating  with  the  meter.  The 
cystoscope  will  distinguish  a  diverticulum  ol  the  bladder,  and  pyo- 
nephrosis has  a  characteristic  tumour. 

In  pyelonephritis  withoul  retention  there  is  a  small  quantity  of 
pus  in  the  urine,  and  catheterization  of  the  ureter  reveals  no 
obstruction. 

In  tuberculous  pyonephrosis  there  are  tubercle  bacilli  in  the  urine 
and  often  tuberculous  lesions  elsewhere;  the  tuberculous  ureter  is 
thick  and  hard,  and  the  general  tests  for  tuberculosis  are  positive. 

Treatment. — 1.  Continuous  drainage  by  ureteral  catheters  of  in- 
creasing calibre  and  daily  lavage  of  the  pelvis  are  seldom  practicable. 

2.  Plastic  operations  arc  referred  to  under  Hydronephrosis  (p.  818), 
but  they  are  usually  rendered  worthless  by  the  extensive  functional 
destruction  of  the  kidney. 

3.  Nephrotomy  may  be  confined  to  incision  and  drainage  of  the 
kidney,  or  an  attempt  may  be  made  to  re-establish  the  lumen  of  the 
ureter.  The  pyonephrotic  sac  is  opened  through  an  oblique  lumbar 
incision,  the  contents  evacuated,  septa  broken  down,  search  made 
for  interstitial  abscesses  and  for  stone,  and  a  large  tube  placed  in  the 
nephrotomy  wound  and  another  outside  the  kidney.  This  operation 
is  rapid  and  devoid  of  shock,  and  is  suitable  for  the  worst  cases.  The 
mortality  is  17-23  per  cent.  After  the  operation  the  general  health 
and  the  function  of  the  second  kidney  show  great  improvement.  In 
27  per  cent,  of  cases  (Krister)  the  wound  closes,  the  sac  shrinks,  and 
the  patient  is  cured. 

A  fistula  remains  in  from  450  to  56  per  cent,  of  the  cases  (Kiister). 
Attempts  to  obviate  it  have  been  made  by  passing  sounds  from  above 
downwards  (Bazy)  or  from  the  bladder  upwards  (Albarran),  and  by 
tying  a  catheter  in  the  ureter.  A  fistula  may  be  cured  by  removal 
of  its  fibrous  wall,  the  opening  up  of  the  sac,  removal  of  calculi,  and 
free  drainage. 

Should  these  fail,  a  urine-collecting  apparatus  may  be  fitted,  or 
nephrectomy  may  be  performed. 

4.  Secondary  nephrectomy  is  indicated  where  septicaemia  persists 
or  exhaustion  is  following  the  prolonged  suppuration.  The  mortality 
is  5-9  per  cent.,  but  to  this  must  be  added  the  mortality  of  nephrotomy 
(23-3  per  cent.),  making  the  total  mortality  29-2  per  cent. 

Primary  nephrectomy  may  be  partial  in  rare  cases.  Total  nephrec- 
tomy is  performed  by  the  lumbar  route,  and  the  best  method  is 
subcapsular  nephrectomy,  the  mortality  of  which  is  17  per  cent. 
(Kiister).  The  chief  danger  is  the  inadequacy  of  the  second  kidney 
from  disease — in  40  per  cent,  of  cases  (Legueu).  Nephrectomy  should 
•not  be  performed  until  the  condition  of  the  second  kidney  has  been 
thoroughly  investigated. 


812  THE  KIDNEY 

RENAL   AND   PERIRENAL   FISTULA 

Of  these  fistulce  the  great  majority  follow  an  operation  ;  a  few 
appear  spontaneously  or  result  from  injury. 

1.  Perirenal  fistulas  unconnected  with  the  urinary  organs. 
—Perirenal  fistula?  unconnected  with  the  urinary  organs  may 
take  origin  in  an  empyema,  appendicitis,  or  other  purulent  collec- 
tion. The  original  seat  of  the  suppuration  is  shown  by  the  history 
of  the  case  or  the  presence  of  scars.  Much  information  can  be  obtained 
by  radiography  after  injection  of  a  bismuth  emulsion. 

Examination  of  the  urine,  cystoscopy,  and  catheterization  of  the 
ureter  on  the  fistulous  side  demonstrate  that  there  is  no  urinary  in- 
fection, and  that  the  ureter  on  this  side  is  patent  and  the  kidney  active. 

2.  Spontaneous  renal  fistulas. — These  are  rare.  A  fistula 
may  follow  wounds  of  the  kidney,  but  is  rarely  permanent.  Pyo- 
nephrosis may  rupture  into  the  perinephric  tissue  and  burrow  to 
the  surface  of  the  body  or  open  into  the  pleural  cavity,  a  bronchus, 
the  stomach,  duodenum,  or  elsewhere.  Calculi  may  be  discharged 
on  the  surface  from  a  spontaneous  fistula. 

The  discharge  is  purulent  or  uropurulent.  Diagnosis  is  usually 
difficult.  To  symptoms  of  pyonephrosis  there  are  superadded  those 
of  rupture  of  a  large  abscess  into  a  bronchus  or  elsewhere.  The  escape 
of  pus  is  usually  intermittent. 

3.  Postoperative  renal  fistulas. — There  is  usually  a  single 
fistula  opening  at  the  posterior  part  of  the  operation  scar,  but  in 
tuberculous  disease  several  intercommunicating  fistulas  may  be 
present.  The  discharge  may  be  pus,  pus  and  urine,  or  pure  urine. 
The  fistulous  track  is  narrow  and  usually  straight.  The  walls  are 
thick,  fibrous,  and  rigid.  The  factors  which  cause  a  permanent  fistula 
may  be  obstruction  of  the  ureter  or  pelvis,  tuberculous  infection  of 
the  track,  a  thick,  hard,  unyielding  track  wall  or  kidney,  or  calculi 
or  concretions  in  the  lumen  of  the  fistula. 

A  fistula  after  nephrectomy  may  be  due  to  necrotic  portions  of 
the  kidney  being  left  in  the  pedicle,  to  an  infected  pedicle  ligature, 
or  to  septic  or  tuberculous  infection  of  the  wound. 

Diagnosis. — Usually  the  cause  of  the  fistula  and  the  condition 
of  the  kidney  are  well  known,  but  it  may  be  uncertain  if  the  fistula 
is  urinary  or  not.  The  discharge  should  be  examined  for  urea.  After 
an  intramuscular  injection  of  methylene  blue  a  urinary  discharge  will 
be  tinged  with  blue.  The  presence  of  stricture  of  the  ureter  and  the 
quantity  of  urine  that  escapes  down  the  ureter  are  ascertained  by 
ureteral  catheterization. 

Treatment. — In  some  cases  nephrostomy  has  been  performed 
with  the  view  of  producing  a  permanent  fistula.  A  modification  of 
Hamilton  Irving' s  suprapubic  drainage  apparatus  should  be  fitted  to 


NONSUPPURATIVE   NEPHRITIS  813 

receive  the  urine  Erom  the  fistula.  In  postoperative  purulent  non- 
urinary  fistula  the  track  should  be  dissected  out,  and  all  side  tracks 
and  pockets  opened  up  and  drained. 

In  urinary  fistula?,  when  the  ureter  is  patent,  drainage  by  a  cat  hetei 
■en  demeure  has  been  recommended. 

Injection  of  the  fistula  with  a  bismuth  paste  may  be  tried  for 
three  weeks.  If  the  ureter  is  impassable  and  the  kidney  retains  a 
considerable  part  of  its  function,  a  plastic  operation  on  the  una  I 
pelvis  is  necessary.  If  the  functional  value  of  the  kidney  is  low 
and  the  second  kidney  healthy,  nephrectomy  should  be  performed. 

SURGICAL  TREATMENT  OF  NON-SUPPURATIVE  NEPHRITIS 

Acute  nephritis. — In  1896,  Reginald  Harrison  recommended  in- 
cision of  the  renal  capsule  and  puncture  of  the  kidney  for  acute  nephritis 
when  associated  with  delayed  convalescence,  with  suppression,  or  with  cardiac 
and  circulatory  complications.  Others  have  recommended  nephrotomy  with 
the  same  object. 

Chronic  Bright's  disease.— 1.  Edebohls,  Pousson,  Casper,  and 
others  have  treated  acute  exacerbations  of  chronic  Bright's  disease  by 
operation  when  medical  treatment  has  failed.  Cases  with  advanced  cardio- 
vascular and  pulmonary  complications  are  unsuitable.  Decapsulation  and 
nephrotomy  have  been  recommended.  Except  in  the  rare  cases  of  proved 
unilateral  disease,  decapsulation  is  rapidly  performed  on  both  sides.  The 
immediate  mortality  is  25  per  cent.,  partly  due  to  the  patients  being  mori- 
bund when  the  operation  was  performed.  Some  cures  have  been  claimed, 
but  improvement  is  usually  temporary. 

2.  In  1901,  Edebohls  suggested  decapsulation  for  chronic  Bright's  disease, 
in  the  belief  that  thus  a  collateral  anastomosis  would  be  established,  and 
provide  a  free  flow  of  blood  through  the  kidney  ;  he  hoped  to  cause  absorption 
of  the  interstitial  fibrous  tissue,  and,  by  removal  of  the  pressure  upon  the 
tubules,  obtain  regeneration  of  the  renal  epithelium.  According  to  Edebohls, 
experiments  show  that,  although  the  fibrous  capsule  invariably  re-forms  in 
a  few  weeks,  the  new  capsule  is  composed  of  loose  connective  tissue  which 
does  not  compress  the  kidney.  A  parietal  anastomosis  has  actually  been 
observed,  which  was  not  strangled  by  contraction  of  the  new  capsule.  The 
kidney  has  also  been  transplanted  into  the  peritoneal  cavity,  and  formed 
adhesions  with  the  serous  membrane  or  the  omentum. 

Although  the  course  of  the  disease  is  generally  uninfluenced,  improve- 
ment is  undoubted  in  some,  and  a  cure  has  been  claimed  in  a  few  cases. 
The  operative  mortality  is  5  per  cent. 

HYDRONEPHROSIS 

Hydronephrosis  is  chronic  aseptic  retention  of  urine  in  the  kidney 
and  renal  pelvis  due  to  ureteral  or  urethral  obstruction. 

Etiology. — Hydronephrosis  is  slightly  more  frequent  in  the 
female  sex  and  on  the  right  side.  It  may  be  bilateral,  especially  when 
the  obstruction  is  urethral. 

Ureteral  obstruction  may  be  caused  by — (a)  changes  in  the  wall 
of  the  ureter  (valves,  folds,  strictures) ;    (b)  obstruction  of  the  lumen 


814 


THE   KIDXKY 


by  calculi,  tumours,  foreign  bodies,  blood-clot ;  (c)  pressure  from 
without  by  tumours,  fibrous  bands  (Fig.  539),  purulent  collections, 
an  aberrant  renal  vessel  (Fig.  540) ;  (d)  kinking  of  the  ureter  from 
undue  mobility  of  the  kidney  ;    (e)  torsion  of  the  ureter. 

Urethral  obstruction  may  be  caused  by  a  congenital  fold  or  dia- 
phragm or  obliteration,  or  more 
frequently  by  stricture  and  enlarged 
prostate. 

Congenital  hydronephrosis  occurs 
before  or  soon  after  birth,  and  when 
unilateral  may  be  due  to  valves  or 
folds  in  or  stenosis  of  the  duct, 
or  to  bending  or  kinking  of  a 
ureter  misplaced  in  the  bladder, 
urethra,  ejaculatory  duct,  seminal 
vesicle,  vas  deferens,  or  vagina. 
More  frequently  congenital  hydro- 
nephrosis is  bilateral,  and  is  due 
to  urethral  obstruction  caused  by 
a  septum  or  imperforate  portion,  a 
cysl .  Tuition  of  the  penis,  or  phimosis. 
In  some  cases  no  obstruction  can 
be  found,  but  the  bladder,  ureters, 
and  kidneys  are  greatly  dilated.  In 
> sases  there  may  be  dilatation 
of  the  colon,  and  the  condition  is 
probably  due  to  changes  in  the 
sympathetic  nervous  system. 

Pathology-  - —  Hydronephrosis 
is  said  to  be  due  to  the  persis- 
tence of  folds  of  the  mucosa  and 
muscle  found  in  the  foetal  ureter, 
and  to  twisting  that  occurs  during 
di-\  clopment  from  the  "Wolffian  duct. 
Hydronephrosis  due  to  abnor- 
mal vessels  passing  to  the  lower 
pole  in  front  of  or  behind  the  ureter 
may  cause  obstruction  by  pressure  upon  that  duct. 

Hydronephrosis  due  to  movable  kidney  is  intermittent,  and  is 
the  result  of  kinking  of  the  ureter.  It  is  also  held  that  the  mobility 
may  be  consequent  upon  the  increased  size  of  the  kidney  already 
hydronephrotic. 

Adhesions  between  the  colon  and  the  pelvis  resulting  from  chronic 
constipation  may  be  the  cause  of  hydronephrosis. 


Fig.  539. — Hydronephrosis  due 
to  bands  of  adhesion  between 
ureter  and  renal  pelvis. 


HYDRONEPHROSIS  :    PATHOLOG1 


815 


W  Inii  a  tense  hydronephrosis  is  found  soon  after  an  injury  it  has 
usually  preceded  the  injury.  Late  traumatic  hydronephrosis  results 
from  stricture  caused  by  injury  to  the  ureter. 

In  hydronephrosis  due  to  calculus  the  stone  may  li''  at  the  outlet 
of  the  pelvis  or  at  the  lower  end  of  the  ureter.  Stenosis  of  the  ureter 
Lin  the  vesical  side  of  the  stone  is  frequently  present. 

A  hydronephrosis  is  "closed"  when  the  obstruction  has  hccium 
complete,  and  "  open  "'  when  urine  escapes.    In  an  open  hydronephrosis 


Fig.    540. — Hydronephrosis    due    to    aberrant    renal    vessels    (operation 
view)  :    aneurysm  needle  under  normal  ureter. 

there  are  attacks  of  retention  due  to  temporary  complete  closure  of 
the  outlet. 

Pathological  anatomy — In  the  early  stage  the  normal  capa- 
city of  the  renal  pelvis  (30-60  minims)  is  increased  to  1  oz.  or  more. 
The  pelvis  is  sac-like  and  the  kidney  hollowed,  but  the  organ  is  not 
enlarged.  The  calyces  become  dilated,  and  the  pyramids  flattened 
and  then  hollowed.  In  the  fully  developed  hydronephrosis  1 1 
is  formed  from  either  the  pelvis  or  the  kidney.  When  the  pelvis  is 
chiefly  affected  it  forms  a  large  globular  sac  on  which  the  hollow  kidney 
is  set  as  a  cap.     When  the  kidney  alone  is  distended  the  surface  shows 


8i6 


THE   KIDNEY 


rounded  bosses  corresponding  to  the  hydronephrotic  pockets ;    the 
pelvis  is  small  and  hidden. 

The  interior  of  the  hydronephrosis  shows  a  single  large  cyst  with 
pockets  (pelvic  type)  (Fig.  541),  or  a  small  central  cavity  with 
numerous  rounded  chambers  leading  from  it  (kidney  type).  The 
lining  membrane  is  smooth,  opaque,  and  white.  If  the  obstruction 
is  situated  at  the  lower  end   of   the   ureter   this   tube  is  thickened, 

dilated,  and  tortuous. 

A  partial  hydronephro- 
sis may  be  formed  by  the 
blocking  of  one  segment 
of  a  double  pelvis  or  the 
malformation  of  a- calyx. 

Even  in  advanced  cases 
there  is  a  considerable 
amount  of  sclerosed  kidney 
tissue  present  in  the  wall 
of  the  sac.  The  contents 
consist  of  urine  with  a 
specific  gravity  of  1005  or 
less.  The  fluid  may  be- 
come mixed  with  blood  and 
form  a  haematonephrosis. 

Symptoms. — In  the 
early  stage  the  kidney  is 
not  palpably  enlarged, 
and  either  there  are  no 
symptoms  or  there  is 
aching  pain  at  the  costo- 
muscular  angle  with  per- 
sistent polyuria.  Later,  a 
rounded  tumour  moving 
with  respiration  and  pre- 
senting the  characters  of  a  renal  tumour  (see  p.  780)  is  found  in  the  loin 
and  may  fill  a  large  part  of  one  side  of  the  abdomen ;  it  is  not  tender. 
The  tumour  may  be  constant  in  size  and  the  urine  normal  in  quan- 
tity, or  there  may  be  "  intermittent "  hydronephrosis  in  which  the 
tumour  for  considerable  periods  completely  disappears.  At  varying 
intervals — often  after  exertion  or  the  drinking  of  a  diuretic  fluid — 
there  are  attacks  of  retention  of  urine  in  the  sac,  accompanied  by 
severe  pain,  diminution  in  quantity  of  urine  passed,  and  sometimes 
complete  suppression.  At  the  same  time  the  tumour  is  large,  tense, 
and  tender.  After  some  hours  or  days  a  large  quantity  of  urine 
is  passed,  the  pain  subsides,  and  the  tumour  disappears. 


Fig.  541. — Hydronephrosis  (pelvic  type) 
due  to  stenosis  of  uretero-pelvic 
function. 


HYDRONEPHROSIS  '7 

On  cystoscopy  there  may  be  in  the  early  stage  increased  frequency 
of  ureteric  contractions  from  polyuria,  ami  in  the  later  stage  diminished 
frequency  from  the  reduction  in  quantity  of  urine.  When  the  block 
is  complete  there  mav  be  an  occasional  gaping  at  the  ureteric  orifice, 

and  when  the  muscular  power  of  the  pelvis  and  ureter  are  completely 
destroyed  the  orifice  is  still. 

A  ureteric  catheter  is  arrested  at  some  part  of  the  ureter  or  uretero- 
pelvic  junction,  where  the  obstruction  is  situated.  It  usually  passes 
after  gentle  manipulation,  and  a  rapid  flow  of  urine  follows. 

Diagnosis.--  The  symptoms  may  lead  to  a  diagnosis  and  the 
X-rays  show  the  presence  of  a  stone.  Frequently  the  diagnosis  is 
uncertain  in  the  early  stages,  and  commencing  dilatation  can  only 
be  ascertained  by  one  of  the  following  methods  : 

1.  Estimation  of  the  capacity  of  the  renal  pelvis  (Kelly)  by  passage 
of  a  ureteric  catheter  and  injection  of  a  known  quantity  of  fluid  after 
removal  of  the  pelvic  contents.  A  capacity  of  30-40  c.c.  shows  a 
moderate  degree  of  hydronephrosis. 

2.  Pyelography  (Voelcker  and  Lichtenberg). — The  pelvis  of  the 
kidney  is  emptied  by  ureteral  catheter  and  a  warm  solution  of  collargol 
(10  or  20  per  cent.)  is  slowly  injected.  A  radiogram  is  taken,  and  a 
shadow  showing  the  contour  of  the  renal  pelvis  and  calyces  is  obtained. 

3.  Proportional  renal  mensuration  (Thomson  Walker). — The  shadow 
of  the  kidney  is  obtained  by  the  X-rays,  and  the  normal  size  is  shown 
by  the  following  measurements  :  The  normal  outer  border  of  the  kidney 
may  be  outlined  as  passing  through  three  points — (a),  on  the  horizontal 
mid -plane  of  the  12th  dorsal  vertebra  at  a  distance  from  its  margin 
equal  to  double  the  narrowest  transverse  measurement  of  the  centrum  ; 
(6)  and  (c),  corresponding  points  on  the  mid-planes  of  the  1st  and  2nd 
lumbar  vertebra?.  The  size  of  the  kidney  can  be  measured  by  passing 
a  ureteric  catheter  opaque  in  alternate  half  inches  and  obtaining  a 
radiogram.  On  the  plate  the  shadow  value  of  half  an  inch  is  obtained, 
and  the  kidney  shadow  is  measured  with  this. 

Prognosis. — If  sepsis  is  superadded  a  pyonephrosis  results, 
and  the  prognosis  is  grave.  Bilateral  hydronephrosis  is  not  incom- 
patible with  an  active  life,  but  eventually  leads  to  suppression  of  urine. 

Treatment.  — ■  Congenital  hydronephrosis  is  rarely  operable  ; 
bilateral  nephrostomy  may  be  performed  if  both  kidneys  are  affected, 
but  the  infants  invariably  die. 

In  cases  of  urethral  obstruction  with  hydronephrosis,  operation 
for  the  relief  of  the  obstruction  should  be  undertaken.  No  direct 
operative  treatment  of  the  hydronephrosis  will  be  necessary. 

In  cases  of  movable  kidney,  early  nephropexy  should  be  performed. 
In  advanced  cases  the  uretero-pelvic  junction  should  be  examined 
both   outside   and   within   the   pelvis.     When   calculus   is   present   it 

3* 


818  thp:  kidney 

should  be  removed  and  the  lumen  of  the  ureter  examined  for  stenosis. 
When  an  aberrant  vessel  is  present,  but  not  closely  related  to  the 
point  of  obstruction,  it  need  only  be  divided  if  it  interferes  with 
the  plastic  operation  for  the  relief  of  the  obstruction.  If  the  vessel 
is  the  cause  of  the  obstruction,  it  should  be  divided  between  two 
ligatures   and  the  lumen  of  the  ureter  examined  for  stenosis. 

Numerous  operations  are  performed  for  congenital  and  acquired 
malformations  of  the  ureter  and  dilatation  of  the  renal  pelvis,  such  as 
pyeloplication  (Israel),  orthopaedic  resection  by  removing  the  part 
of  the  pelvis  and  kidney  below  the  level  of  the  outlet  (Albarran),  re- 
section of  a  large  triangular  flap  of  the  pelvis  (Thomson  Walker), 
anastomosis  of  the  ureter,  or  pyelo -ureteral  anastomosis,  which  may 
be  lateral  implantation  of  the  cut  ureter  (uretero-pyeloneostomy)  or 
direct  anastomosis  of  a  hydronephrotic  sac  with  the  bladder  (nephro- 
cvsto-anastomosis).  Finally,  there  are  plastic  operations  on  stric- 
tures and  valves,  such  as  splitting  of  a  valve  and  uretero-pyeloplasty. 
Nephrostomy,  i.e.  the  incision  and  permanent  drainage  of  the  sae,  is 
sometimes  performed. 

Primary  nephrectomy  is  indicated  when  the  sac  is  very  large  and 
its  wall  thin  and  fibroid,  but  only  in  cases  where  it  has  been  proved 
that  a  second  kidney  is  present  and  efficient.  Secondary  nephrectomy 
is  required  when  conservative  operations  have  failed. 

TUMOURS    OF    THE    KIDNEY 

Benign  Growths 

Benign  growths  form  less  than  7  per  cent,  of  renal  growths.  Adenoma 
is  met  with  as  a  single,  rarely  multiple,  cherry-sized  subcapsular  tumour 
of  greyish-white  or  pink  colour  and  with  a  well-defined  fibrous  capsule. 
It  usually  occurs  in  kidneys  the  seat  of  chronic  interstitial  nephritis. 
The  microscopical  structure  may  be  acini  lined  with  cylindrical  epithelium, 
and  containing  papillary  formations  (papillary  adenoma)  or  solid  or  hollow 
masses  of  cylindrical  epithelium  (tubular  adenoma).  Lipoma  is  a  small 
(very  rarely  large)  single  or  multiple  subcapsular  tumour.  Fibroma  forms 
fibrous  nodules  in  the  cortex  or  medulla.  Leiomyoma  is  rare,  and  ori- 
ginates in  the  smooth  muscle  of  the  capsule.  Small  benign  tumours  are 
found  post  mortem ;  large  growths  are  indistinguishable  clinically  from 
malignant  growths. 

Malignant  Growths 

The  varieties  met  with  are— (1)  carcinoma,  (2)  sarcoma,  (3)  hyper- 
nephroma, (4)  mixed  tumours  of  embryonic  type. 

The  great  majority  of  renal  growths  are  found  under  the  age  of 
5  or  over  40  years. 

The  right  kidney  is  more  frequently  affected  ;  bilateral  growths  are 
rare.     Men  are  more  often  affected  than  women  (227  to  73,  Albarran). 

Etiology. — The  growths  in  infancy  and  childhood  are  congenital- 


MALIGNANT   DISEASE 


819 
Stone 


There  is  no  dired  evidence  thai    injury  causes  renal  growths 
may  coexist,  but   is  not   an  important   Eactoi  in  etiology. 

Pathology    and    histology.      1.  Carcinoma Of    recent 

years  it  has  been  shown  that  carcinoma  is  a  rare  growth  of  the  kidney 
(7  per  cent.,  Garceau).  It  originates  in  the  renal  tubules,  and  shows 
the  following  varieties  df  structure,  viz.  (a)  diffuse  infiltration,  the  cells 


Fig.  542. — Adeno-carcinoma, 
large  cyst  and  multiple 
small   cysts   of  the  kidney 


in  some  parts  being  arranged  in  masses  or  alveoli — adeno-carcinoma 
(Fig.  542)  ;  (b)  tubules  lined  with  epithelium  closely  resembling  the 
structure  of  normal  kidney — adenoma-carcinoma  ;  (c)  acini  contain- 
ing papillary  growths — papillary  adeno-carcinoma. 

The  tumours  are  usually  small,  and  on  section  are  grey,  yellow, 
or  brown  in  colour,  with  tracts  of  fibrous  tissue. 

2.  Sarcoma  is  most  common  in  children,  and  is  more  often 
bilateral  than  carcinoma.  It  may  reach  enormous  proportions  (33  lb., 
Van  der  Byl).  The  growth  may  arise  from  the  capsule,  from  the  peri- 
vascular connective  tissue,  or  in  the  substance  of  the  kidney. 

On  section  the  surface  has  a  greyish,  brain-like  appearance,  and 
an  alveolar  arrangement  in  parts,  and  there  is  an  ill-defined  capsule. 
These  tumours  are  of  the  spindle-  and  small  round-celled  varieties. 


S2o  THE   KIDNEY 

3.  Hypernephroma. — These  tumours  in  some  respects  resemble 
the  cortex  of  the  suprarenal  gland  in  structure,  and  Grawitz  showed 
that  they  take  origin  in  small  aberrant  nodules  of  suprarenal  tissue 
found  in  the  cortex  of  the  kidney  beneath  the  capsule.  Stoerk  has 
recently  disputed  their  suprarenal  origin,  and  looks  upon  them  as 
papillomatous  in  structure.  More  recently,  Wilson  and  Willis  have 
shown  that  they  arise  from  the  Wolffian  body. 

The  growths  are  most  frequently  found  under  the  capsule  and  in 
the  upper  pole  of  the  kidney,  the  right  being  more  frequently  affected 
than  the  left,  and  male  subjects  more  often  than  female.  They  are 
very  rarely  bilateral,  and  are  the  most  common  form  of  renal  growth. 
The  growth  may  become  active  at  any  age.  It  is  surrounded  by  a 
firm  fibrous  capsule,  and  its  substance  is  broken  up  by  fibrous  bands. 
The  presence  of  a  large  quantity  of  fat  in  the  cells  gives  the  growth 
a  characteristic  yellow-red  colour.  Patches  of  necrosis  and  haemorrhages 
are  common.  Microscopically  there  is  a  network  of  capillary  vessels, 
and  set  directly  upon  these,  in  one  or  several  rows,  are  large  polyhedral 
•cells  with  clear  protoplasm  containing  fat  droplets.     (Fig.  543.) 

4.  Mixed  tumours — These  tumours  usually  arise  during  the 
first  four  years  of  life.  There  is  a  basis  of  immature  connective  tissue, 
the  cells  being  round,  oval,  or  spindle-shaped.  In  this  are  found 
embryonic  striped  muscle  fibres,  also  non-striped  muscle  fibres,  car- 
tilaginous nodules,  fatty  and  elastic  tissue,  and  epithelial  tubules. 
When  striped  muscle  fibres  are  abundant  the  growth  is  termed  a 
"  rhabdo-myo-sarcoma  "  ;  when  the  epithelial  elements  are  numerous 
the  name  "  embryonic  adeno-sarcoma  "  is  used.  These  growths  arise 
from  the  tissues  of  the  sinus  of  the  kidney  and  distend  the  organ 
(Bland-Sutton). 

Extension  and  metastasis. — New  growths  of  the  kidney 
spread  along  the  renal  veins  to  the  vena  cava,  and  extend  to  the  peri- 
renal tissues,  suprarenal  gland,  lymph-glands,  along  the  aorta  and 
vena  cava,  renal  pelvis,  and  ureter.  The  most  frequent  seats  of  metas- 
tatic deposit  in  renal  growths  are  the  lungs,  liver,  lymph-glands,  bones, 
and  rarely  the  second  kidney,  the  pleura,  omentum,  suprarenal  gland, 
and  brain. 

Concomitant  disease  of  the  kidney,  such  as  movable  kidney, 
tuberculosis  of  the  kidney,  or  calculus,  occurs,  but  has  no  etiological 
value. 

Symptoms. — The  cardinal  symptoms  are  hsematuria  and  tumour. 
Hsematuria  is  present  in  over  90  per  cent,  of  adult  cases,  and  is  the  first 
symptom  in  70  per  cent.  In  children  it  is  much  less  frequent  (15 
per  cent.),  and  occurs  late.  The  hematuria  is  spontaneous,  inter- 
mittent, and  capricious,  and  is  but  little  influenced  by  rest.  The  blood 
is  well  mixed  and  varies  in  quantity.     Ureteral  clots  like  long,  slender 


MALIGNANT    DISEASE  821 

worms  are  sometimes  found,  01  there  may  be  small  maggot-like  clots 
in  blood-stained  urine. 

dots  may  cause  ureteric  ruin-  in  passing,  and  copious  bleeding 
may  till  the  bladder  with  clotted  blood  and  cause  strangury  and 
retention  of  urine. 

Palpable  tumour  is  present   in  the  advanced  stage  of  nearly  all 


-:•    .'-'"-'-■'     -"*  i  ...  •.  .•-.•- C  il 


Fig.  543. — Hypernephroma  of  kidney,  papillary  type. 

growths.  In  children  it  is  the  initial  symptom  in  one-third  of  the 
ca>es.    The  tumour  moves  with  respiration  until  it  is  fixed  by  adhesions. 

Pain  may  be  due  to  the  passage  of  clots  along  the  ureter,  or  there 
may  be  renal  aching  from  tension,  which  is  unaffected  by  movement 
and  only  temporarily  relieved  by  drugs.  Costal  neuralgia  and  radiating 
pain  or  sciatica  from  invasion  of  nerves  by  the  growth  may  be  present. 

Portions  of  the  growth  may  occasionally  be  passed  in  the  urine. 
Albuminuria  is  due  to  toxic  nephritis.  Polyuria  is  sometimes  observed. 
Varicocele  may  develop  suddenly  or    slowly,  and  is    usually  a    late 


322  THE   KIDNEY 

symptom.  It  is  due  to  pressure  of  enlarged  glands  or  of  the  growth, 
or  to  engorgement  of  the  capsular  vein  which  anastomoses  with  the 
spermatic  vein.  It  disappears  after  nephrectomy,  and  should  not  be 
considered  a  contra-indication  to  operation.  The  development  of  a 
varicocele  in  a  man  past  35  should  always  lead  to  careful  examination 
for  renal  tumour.  Cachexia  appears  late.  A  specific  fever  of  a  re- 
mittent or  recurrent  type  is  observed  in  8  per  cent,  of  cases  (Israel). 
Increased  arterial  tension  has  been  noted,  and  in  hypernephroma  an 
abnormally  rapid  pulse  is  not  uncommon. 

The  X-rays  give  a  dense  shadow  with  indefinite  outline,  and  metas- 
tatic nodules  in  the  lungs  can  be  clearly  demonstrated  by  this  means. 

Course  and  prognosis. — The  average  duration  of  the  disease 
from  the  appearance  of  the  first  symptom  to  the  fatal  issue  is  three 
and  a  half  years  (Garceau). 

Diagnosis — Where  hsematuria  is  the  only  symptom  the  disease 
can  be  localized  to  one  kidney  by  the  cystoscope.  Portions  of  the 
growth  may  be  found  in  the  urine,  but  exploration  of  the  kidney  is 
the  sole  certain  method  of  diagnosis.  Where  tumour  is  the  only 
symptom  an  exploratory  laparotomy  may  be  necessary  to  establish 
the  diagnosis.  Tumour  with  hematuria,  without  other  symptoms, 
is  characteristic  of  growth. 

Treatment. — Palliative  treatment  consists  in  the  administration 
of  ergot,  adrenalin,  or  calcium  lactate  to  control  haemorrhage,  and  of 
opium  and  morphia  to  soothe  pain.  Nephrectomy  is  sometimes 
justifiable  for  the  relief  of  pain,  even  when  secondary  growths  are 
known  to  be  present,  but  is  seldom  necessary. 

Early  total  nephrectomy  alone  holds  out  a  prospect  of  cure.  Opera- 
tion is  contra-indicated  where  (a)  the  growth  has  spread  beyond  the 
kidney,  (6)  the  second  kidney  is  functionally  inadequate,  (c)  the  patient 
is  weak  and  cachectic,  or  (d)  the  heart  is  dilated  and  feeble. 

In  all  large  growths  the  peritoneum  should  be  opened  and  the 
peritoneal  aspect  of  the  tumour  examined.  The  liver  and  lymph- 
glands  should  be  examined.  The  efficiency  of  the  second  kidney  must 
be  previously  determined,  and  thoracic  radiograms  taken  to  exclude 
pulmonary  metastases. 

The  ideal  operation  should  remove  the  kidney  and  growth,  adipose 
capsule,  the  lymphatic  vessels,  and  the  suprarenal  capsule.  Nephrec- 
tomy is  performed  by  the  lumbar  route.  The  mortality  of  this  opera- 
tion for  renal  growth  has  fallen  during  recent  years  from  76  per  cent. 
(1885)  to  22  per  cent.  (1902). 

Recurrence  takes  place  in  60  per  cent,  of  cases,  and  in  over  70 
per  cent,  of  these  it  occurs  during  the  first  year.  Recurrence  is  rare 
after  the  third  or  fourth  year,  but  has  been  described  after  four  and 
a  half  years  (Abbe)  and  five  years  (Witzel). 


TUMOURS   ()!-    RENAL    PELVIS 


823 


From  7  to  1"  per  oent.  of  cases  survive  a1  the  end  oJ  the  fourth 
year  withoul  recurrence.  In  children  the  operative  mortality  is 
higher  (25  to  •"><>  per  pent.),  and  recurrence  is  more  rapid  and  certain 
(67  to  81  per  cent,  of  survival.-).  Cases  are  recorded  in  which  the 
patients  were  alive  and  well  eighteen  years  (Malcolm),  five  years 
(Israel),  and  four  years  (Doderlein,  Abbe)  after  operation. 

TUMOURS   OF   THE    RENAL   PELVIS   AND    ORETER 
Primary  growths  of  the  renal  pelvis  are  very  rare.    Calculi  have 

heen      present     in     t  lie 
pelvis  in  some  eases. 

Pathology.- 
Epithelial  tumours 
(papilloma,  and  epi- 
thelioma) are  most 
frequent,  while  meso- 
blastic  tumours 
(sarcoma,  myxoma, 
rhabdo  -  myoma ,  and 
lipoma)  are  rare. 

Papilloma  is  the 
commonest  form,  and 
is  situated  at  the 
uretero  -  pelvic  junc- 
tion or  in  the  ureter, 
and  may  protrude  into 
the  bladder.  The 
tumour  closely  resem- 
bles vesical  papilloma 
and  tends  to  become 
malignant.  (Fig.  544.) 
The  growths  spread 
into  the  kidney  and 
along  the  ureter.  Columnar-celled  carcinoma  is  less  frequent,  and 
forms  a  nodular  growth  which  rapidly  spreads  to  neighbouring  struc- 
tures and  forms  metastases. 

Obstruction  at  the  outlet  of  the  pelvis  may  cause  hydronephrosis, 
which  may  become  hsematonephrosis  or  pyonephrosis. 

Symptoms. — The  symptoms  are  hematuria,  pain,  and  tumour. 
Attacks  of  renal  retention  occur,  accompanied  by  intense  renal  and 
ureteral  pain  and  rapid  enlargement  of  the  kidney.  On  cystoscopy 
a,  tumour  may  be  seen  projecting  from  the  ureter,  and  the  ureteral 
catheter  may  draw  blood  and  urine  from  the  renal  pelvis. 

Treatment. — Nephrectomy,  combined  if  necessary  with  ureter- 


Fig.  544. — Malignant  growth  of  kidney  and 
papillomatous  growth  of  renal  pelvis. 


S24  THE   KIDNEY 

ectomy,  is  the  only  radical  method.  It  may  be  necessary  to  remove 
the  lower  part  of  the  meter  through  the  bladder  after  suprapubic 
cystotomy,  and  to  take  with  it  an  area  of  bladder  wall  around  the 
ureteric  orifice.     Recurrence  almost  invariably  takes  place. 

CYSTS    OF    THE    KIDNEY 

Apart  from  retention  cysts  of  the  kidney  due  to  obstruction  in 
the    renal    pelvis    (hydronephrosis,    pyonephrosis),    there    are    several 
varieties  of  cysts,  some  of  doubtful  origin.     These  are  as  follows  : — 
Multiple  cysts  in  chronic  nephritis. 
Dermoid  cysts. 

Polycystic  kidney  and  congenital  cystic  kidney. 
Solitary  cysts  or  serous  cysts. 
Hydatid  cysts. 

Dermoid  cysts  are  very  rare,  only  five  or  six  examples  having 
been  recorded. 

Polycystic  Kidney  (Congenital  Cystic  Kidney) 

In  this  condition  the  kidney  is  transformed  into  a  collection  of 
cysts,  and  has  an  appearance  almost  like  a  bunch  of  grapes.  The 
disease  may  occur  in  several  members  of  the  same  family.  Although 
probably  always  congenital,  if  not  obvious  at  birth  it  may  not  con- 
spicuously develop  till  adult  life.  It  is  most  commonly  observed 
during  infancy,  or  between  the  ages  of  40  and  50.  Women  are  more 
frequently  affected  than  men.  The  disease  is  practically  always 
bilateral,  though  it  may  be  more  advanced  in  one  kidney  than  in  the 
other.  The  organ  may  reach  enormous  proportions,  and  is  converted 
into  a  mass  of  cysts  varying  from  a  pin's  head  to  a  cherry  in  size. 

The  contents  are  a  clear  3-ellow,  sometimes  brownish,  fluid  which 
holds  in  suspension  cortical  and  columnar  epithelial  cells,  tube  casts, 
red  blood-corpuscles,  leucocytes,  and  occasionally  uric-acid  and  cal- 
cium -  oxalate  crystals.  Urea  is  present  in  small  quantities,  and 
albumin,  phosphates,   chlorides,   and  cholesterin. 

The  intercystic  kidney  tissue  may  be  invisible  to  the  naked 
eye.  The  wall  of  the  cysts  consists  of  connective  tissue  lined  by 
columnar,  cubical,  or  flattened  epithelium. 

Cystic  changes  are  present  in  the  liver  in  18  per  cent,  of  cases. 
The  liver  cysts  are  due  to  dilatation  of  biliary  canals,  and  are  not 
usually  numerous. 

In  a  few  cases  cystic  changes  have  also  been  found  in  the  pancreas, 
spleen,  thyroid,  ovaries,  uterus,  and  seminal  vesicles.  Hypertrophy 
of  the  heart  and  arterio-sclerosis  are  frequently  present. 

Symptoms. — If  the  cystic  condition  is  very  advanced  in  the 
infant,  the  large  size  of  the  kidney  may  cause  difficulty  in  labour, 
and  the  child  usually  soon  dies  with  uraemic  symptoms. 


SOLITARY   CYSTS  825 

In  tlic  adult,  many  caseB  present  no  Bymptoms  al  all.  Frequently, 
however,  after  a  long  latenl  period,  a  renal  tumour  appears  with  some- 
what indeterminate  Bymptoms,  which  ultimately  progress  to  those 
of  renal  failure. 

Iii  the  second  or  tumour  stage  a  large  swelling  presenting  the 
renal  characteristics  appears  on  one  side,  the  second  kidney 
not    yrt    being   enlarged  on  palpation.     Tenderness  is  rare;    pain  is 

late,  and  consists  of  a  dull  aching  in  the  loin,  with  an  occasional 
colic  due  to  the  passage  of  clots.  There  may  be  albuminuria  and 
pronounced  polyuria,  interrupted  by  periods  of  oliguria.  Bsematuria, 
when  present,  is  Blight  and  Intermittent.  In  the  last  stage  there  is 
bilateral  tumour,  the  urine  becomes  scanty  and  anuria  supervenes. 
Treatment. — From  the  fact  that  the  disease  is  practical!} 
always  bilateral,  surgical  intervention  is  ill  advised.  Nephrotomy 
with  the  evacuation  of  large  cysts  has  been  performed  for  pain  and 
pyuria.     Nephrectomy  is  useless  owing  to  the  bilateral  distribution. 

Solitary    Cysts 

Large  cysts  of  the  kidney,  sometimes  wrongly  termed  "serous"  cysts, 
are  very  rare.  (Fig.  542.)  They  are  usually  unilateral.  Generally  single,  and 
of  the  size  of  an  orange  or  larger,  the  cyst  lias  a  thin,  transparent  fibrous 
wall  incompletely  lined  with  flattened  or  cubical  epithelium,  and  is  filled 
with  a  clear  amber  fluid  containing  albumin,  chlorides,  phosphates,  and  traces 
of  urea,  and  occasionally  blood.  The  interior  frequently  shows  the  remains 
of  septa.  Very  rarely  the  cysts  communicate  with  the  pelvis.  They  are 
generally  held  to  be  retention  cysts  from  blocking  of  tubules. 

Symptoms. — Only  the  largest  cysts  cause  symptoms.  Dull  aching 
pain,  or  more  rarely  sudden  severe  lumbar  pain  and  vesical  tenesmus,  has 
been  noted.  A  large  cyst  may  produce  pressure  on  the  great  veins  and  on 
the  bowel.  The  urine  is  normal.  The  tumour  has  the  characteristics  of  a 
renal  tumour,  and  is  most  likely  to  be  confused  with  hydronephrosis  or  new 
growth.  The  fixed  volume,  even  after  ureteral  catheterization,  and  the 
normal  outline  of  the  renal  pelvis  on  injection  of  collargol  (pyelography), 
show  that  there  is  no  dilatation  of  the  pelvis.  A  cyst  of  large  size  may  be 
mistaken  for  an  ovarian  cyst.  A  correct  diagnosis  is  made  in  only  8  per 
cent,  of  cases. 

Treatment. — The  cyst  may  be  brought  up  to  the  surface  and  opened, 
and  the  cyst  wall  stitched  to  the  skin.  This  is  followed  by  fistula  in  half 
the  cases. 

Resection  of  the  pouch  should  he  carried  out  whenever  possible.  The 
salient  part  of  the  cyst  wall  is  cut  away,  and  the  portion  of  cyst  wall  within 
the  kidney  cauterized. 

Partial  nephrectomy  may  be  performed  if  the  cyst  is  at  one  pole.  Total 
nephrectomy  is  the  usual  treatment  for  very  large  cysts. 

Hydatid    Cysts 

The  kidney  is  only  affected  in  -066  per  cent,  of  cases  of  hydatid  disease 

(Thomas). 

Pathology. — The  embryo  is  arrested  in  the  capillary  plexus  of  the 
convoluted  tubules,  usually  at  one  pole.     The  growth  is  slow,  but  the  cyst 


826  THE    KIDNEY 

may  finally  increase  rapidly  in  size.  The  neighbouring  kidney  tissue  is  destroyed 
by  pressure.  Active  growth  sometimes  ceases  and  the  cyst  dies,  shrinks. 
and  the  walls  become  calcified,  the  fluid  being  absorbed  and  the  contents 
converted  into  a  putty-like  mass.  A  large  cyst  may  rupture  into  the  pelvis 
of  the  kidney,  and  the  daughter  cysts  be  passed  in  the  urine.  The  cyst  may 
now  collapse  and  die,  or  it  may  refill  and  rupture  again  after  some  years. 
Rupture  into  the  stomach,  intestine,  lung,  or  peritoneal  cavity  may  take 
place.     Suppuration  frequently  follows  rupture,  and  is  a  grave  complication. 

Symptoms. — A  painless,  globular  tumour  not  moving  with  respiration 
is  found  in  the  position  of  the  kidney,  which  may  be  detected  attached  to  the 
tumour.  Percussion  is  dull  or  tympanitic  on  the  anterior  surface.  The  cyst 
is  hard  and  fluctuation  is  seldom  detected.     The  urine  is  normal. 

Rupture  occurs  very  frequently,  and  is  accompanied  by  renal  pain  and 
ureteric  colic,  vomiting,  and  collapse.  The  urine  becomes  turbid,  is  alkaline, 
and  contains  small  hydatid  cysts  (complete  or  ruptured),  scolices,  booklets, 
fat  droplets,  and  sometimes  blood.  Frequent  micturition,  strangury,  and 
even  retention  of  urine  may  be  caused.  Rupture  may  be  followed  by  toxaemia, 
high  temperature,  urticaria,  and  occasionally  convulsions. 

Diagnosis. — Hydatids  grow  very  slowly,  are  painless,  and  show  no 
variations  in  size.  Ureteral  catheterization  and  pyelography  exclude  dilata- 
tion of  the  kidney.  Polycystic  kidney  is  bilateral,  while  hydatid  and  solitary 
cysts  are  unilateral.  Exposure  of  the  individual  to  contagion,  a  hydatid 
thrill,  booklets  or  cysts  in  the  urine,  when  rupture  has  taken  place,  assist 
in  diagnosis.  Eosinophilia  is  present,  and  recently  the  diagnostic  reaction 
known  as  "  fixation  of  the  complement  "  lias  been  successfully  employed. 

Treatment. — Nephrectomy  should  only  be  performed  when  con- 
servative measures  are  impossible,  or  when  suppuration  or  rupture  has  taken 
place.  The  mortality  is  19  per  cent.  Resection  or  partial  nephrectomy 
is  only  applicable  in  small  cysts. 

The  pouch  may  be  "  marsupialized."  and  washed  daily  with  iodine  solu- 
tion. After  removal  of  as  much  of  the  cyst  as  possible,  the  opposing  surfaces 
may  be  stitched  together  with  catgut. 

PERIRENAL    TUMOURS 

These  are  rare,  but  of  wide  variety.  Lipoma,  fibroma,  fibro-myoma, 
and  mixtures  of  these,  may  grow  from  the  capsule  or  at  the  renal  hilum, 
but  are  usually  small ;  sarcomas  are  also  found.  Mixed  tumours  are  rare ; 
they  arise  from  Wolffian  remains  and  resemble  renal  mixed  tumours  in 
structure.  Perirenal  cysts  are  believed  to  arise  in  Wolffian  remains  or  in 
detached  portions  of  embryonic  peritoneum  (Rambaud). 

Perirenal  tumours  may  be  large  and  cause  pressure-atrophy  of  the  kidney 
or  obstruction  of  the  ureter. 

Tumour  formation,  slow  except  in  sarcomas,  is  the  only  constant 
symptom,  but  pressure  symptoms  may  be  present.  The  urine  is  normal. 
Early  removal  is  required,  by  the  lumbar  route  for  small  tumours,  trans- 
peritoneally  for  large  ones.  The  kidney  should  be  saved,  if  possible,  except 
when  the  growth  is  sarcomatous. 

TUMOURS    OF    THE    SUPRARENAL    GLAND 

These  growths  are  rare  ;  they  resemble  the  structure  of  the  gland,  and 
are  grouped  under  the  name  hyperneplrroma.  Isolated  examples  have  been 
described  of  glioma,  neuroma,  glio-fibroma,  angioma,  lymphangioma,  lipoma, 
and  cysts.     About  one-third  of  the  new  growths  of  the  adrenals  are  found 


TUMOURS   OF   SUPRARENAL   GLAND 

in  infanoj  and  childhood.  Females  ate  more  frequently  affected  than  males, 
and  thr  lefl  Bide  more  often  than  the  right.  Hypernephroma  may  be  benign 
or  malignant,  and  lias  the  histological  characters  of  the  cortex  of  the 
suprarenal  gland.  There  is  a  framework:  of  capillar;  blood-vessels  upon 
which  large,  polygonal,  frequently  vacuolated  cells  are  regularly  arranged. 
Jn  the  meshes  of  the  vascular  network  the  cells  become  arranged  in  alveolar 
form  or  in  long  columns.  The  vacuoles  in  the  cells  frequently  contain  fat, 
and  pigmenl  granules  may  be  found  in  the  protoplasm.  The  tumours  are 
single  or  multiple.  They  are  rounded,  possess  a  fibrous  capsule  and  a  charac- 
teristic yellow  colour,  and  frequently  Bhow  hemorrhages.  In  the  benign 
hypernephroma  the  cells  are  smaller,  more  uniform  in  size,  and  regular  in 
arrangement.  Transition  between  simple  and  malignant  forms  is  seen  in  the 
same  tumour.  In  malignant  growths  metastases  take  place  by  the  blood- 
stream, and  deposits  are  found  in  the  lungs,  bones,  and  liver. 

Symptoms.  -Hematuria  is  very  rare,  and  is  due  to  passive  congestion 
of  the  kidney  from  invasion  of  the  renal  vein.  Progressive  emaciation  with 
profound  anaemia  is  the  most  characteristic  feature;  anorexia,  vomiting, 
.constipation,  and  .sometimes  oedema  are  observed.  Pigmentary  changes  very 
rarely  develop.  In  children  there  may  be  arrest  of  mental  development. 
There  may  be  unilateral  hypertrophy,  precocious  puberty,  and  excessive 
genital  development.  At  first  hidden  under  the  rihs,  the  tumour  is  later 
detected  in  the  hypochondriac  region  behind  the  bowel.  The  kidney  may 
sometimes  be  recognized  below  it.  Pain  is  frequent  and  is  sometimes  referred 
to  distant  parts.     The  growth  is  often  only  discovered  post  mortem. 

Diagnosis. — The  majority  of  cases  are  diagnosed  as  renal  growths. 
The  characteristic  features  are  the  absence  of  changes  in  the  urine,  early 
and  extreme  emaciation,  pigmentary  and  developmental  changes,  the  level 
of  the  tumour  at  the  7th  or  8th  costal  cartilages,  the  lower  border  of  the 
.suprarenal  growth  being  broad  and  almost  horizontal.  Pyelography  may  aid 
in  distinguishing  the  origin  of  the  growth. 

Prognosis  and  treatment. — The  average  duration  of  life  after 
symptoms  appear  is  from  six  to  ten  months  (Ramsay).  Early  removal  of  the 
growth  with  the  kidney  is  the  only  radical  method.  There  is  danger  of  severe 
haemorrhage  and  of  opening  the  pleural  cavity  during  separation  of  adhesions. 
Rapid  recurrence  after  removal  is  the  rule. 

TUBERCULOSIS    OF    THE    KIDNEY    AND    URETER 

Tuberculosis  of  the  urinary  organs  may  exist  alone,  or  may  be 
secondary  to  tuberculosis  of  the  genital  system  or  to  tuberculosis 
of  some  other  organ  such  as  the  lung.  The  combination  of  genital 
and  urinary  tuberculosis  is  very  frequent  in  the  male,  rare  in  the 
iemale. 

Tuberculosis  of  the  kidney  is  said  to  be  primary  or  secondary. 
The  term  "  primary  "  is  used  in  the  narrow  sense  that  the  kidney 
is  the  primary  focus  in  the  urinary  system. 

Renal  tuberculosis  occurs — (1)  as  a  part  of  acute  miliary  tuber- 
culosis, both  kidneys  being  strewn  with  miliary  tubercles  ;  (2)  as  a 
tuberculous  infiltration  of  the  kidney.  Miliary  tuberculosis  is  met 
with,  especially  in  early  childhood,  as  an  insignificant  part  of  a 
szeneral  tuberculous  infection.     It  has  no  surgical  interest. 


828  THE   KIDNEY 

Method  of  infection. — The  bacilli  roach  the  kidney  by 
one  of  three  paths — (1)  ascending  (secondary  renal  tuberculosis)  ; 
(2)  hematogenous  (primary  renal  tuberculosis)  ;  (3)  lymphatic. 

Although  ascending  tuberculosis  has  been  proved  experimentally 
to  be  possible,  it  is  doubtful  if  it  ever  occurs  clinically. 

Hematogenous  infection  is  the  method  by  which  the  kidney  is 
attacked  in  the  great  majority  of  cases.  Lymphatic  infection  from 
the  mediastinal  lymph-glands  infected  from  a  bygone  pleurisy  is  said 
to  occur  frequently  (Brongersma),  but  proof  of  this  is  lacking. 

Etiology. — Renal  tuberculosis  is  most  frequent  between  the 
ages  of  20  and  40  ;  it  is  uncommon  in  childhood  and  rare  in  old  age. 
Women  are  the  more  frequently  affected,  and  the  right  kidney  more 
often  than  the  left.  Tuberculous  disease  is  unilateral  in  from  85 
per  cent.  (Legueu)  to  92  per  cent.  (Kronlein)  of  cases  in  the  early 
stage.  In  the  late  stage  it  is  bilateral  in  53"3  per  cent.  In  children 
it  is  bilateral  in  53  per  cent,  of  cases.  Secondary  infections  withi 
Bacillus  coli,  the  streptococcus,  and  the  staphylococcus  may  occur. 

Pathological  anatomy. — The  following  varieties  may  be 
enumerated  : — 

1.  Miliary  tuberculosis. 

2.  Ulcero-cavernous  form. — This,  the  common  form,  com- 
mences with  congestion  and  ulceration  at  the  apex  of  a  pyramid  at 
one  pole,  and  progresses  from  the  pelvis  outwards  until  the  pyramid 
is  entirely  hollowed  out.  Other  pyramids  are  attacked,  and  the 
pockets  may  unite  to  form  larger  cavities.     (Plate  103.) 

Tubercles  may  dot  the  cortex,  singly  or  in  groups,  or  may  entirely 
permeate  it.  At  the  mouth  of  a  calyx  or  of  a  large  branch  of  the  pelvis 
into  which  the  ulcerated  calyces  open  there  is  thickening  of  the  wall 
and  narrowing  of  the  outlet,  which  may  temporarily  shut  off  this 
part  from  the  urinary  tract. 

3.  Tuberculous  hydronephrosis. — Where  thickening  and  con- 
traction of  the  wall  of  one  part  of  the  pelvis  or  of  a  single  calyx 
continues  to  the  point  of  obliteration,  or  where  the  same  process 
develops  at  the  outlet  of  the  ureter,  a  partial  or  total  tuberculous 
hydronephrosis  results.  The  fluid  content  is  pale  and  turbid  with 
white  flakes,  and  the  lining  irregular  and  greyish-white. 

Parenchymatous  and  interstitial  nephritis  and  waxy  disease  are 
observed  in  the  kidneys  of  tuberculous  patients,  and  are  due  to  the 
poisons  produced  by  the  tubercle  bacillus. 

Tuberculous  lesions  arc  found  in  the  renal  pelvis  and  ureter.  Ste- 
nosis of  the  pelvic  outlet  causes  hydronephrosis.  The  fatty  capsule 
and  fat  around  the  renal  vessels  are  greatly  thickened,  coarse,  fibrous, 
and  densely  adherent.  Enlarged  lymph-glands  arc  present.  Giant-cell 
systems  may  be  found  in  the  perirenal  fat. 


Tuberculous  disease  of  the  kidney. 


Plate  103. 


RKNAL  TUBERCULOSIS  829 

Symptoms.  1.  Vesical  symptoms.— The  symptoms  may  be 
entirely  confined  to  the  bladder.  Theonsel  is  insidious,  with  gradually 
increasing  frequency  of  micturition,  at  first  during  the  day,  and  later 
al  night  also. 

2.  Changes  in  the  urine.— Polyuria  is  an  early  symptom.  It 
exists  only  on  the  diseased  side,  and  is  more  marked  al  night.  The 
urine  is  abundant,  very  pale  and  opalescent,  faintly  acid  01  neutral, 
and  hazy,  with  a  small  amount  of  pus  well  mixed  with  the  mine.  The 
urea  and  chlorides  are  reduced.  Hematuria  may  he  entirely  absent, 
or  only  present  in  microscopic  amount.  There  may  be  slight  persistent 
terminal  hematuria  or  a  considerable  outburst  of  haemorrhage,  which 
may  precede  other  symptoms  by  many  months  and  recur  during  the 
course  of  the  disease.  Albuminuria  may  be  present  independently  of 
pyuria  or  hematuria. 

3.  Pain — The  kidney  may  be  completely  destroyed  without  pain, 
but  renal  aching  is  sometimes  present,  and  the  patient  may  be  unable 
to  lie  on  the  affected  side.  Ureteral  colic  may  be  caused  by  the  passage 
of  clots  or  debris.  Pain  at  the  neck  of  the  bladder  and  at  the  end  of 
the  penis  is  due  to  evstitis. 

4.  Other  symptoms. — On  examination  the  tuberculous  kidney 
is  not  usually  enlarged.  If  palpable  it  may  be  hard  and  irregular. 
It  is  frequently  tender.  In  the  late  stage  it  may  be  small,  shrunken, 
and  not  palpable,  or  it  may  be  hydronephrotic  and  enlarged. 

There  is  frequently  tenderness  along  the  line  of  the  ureter,  which 
can  be  felt  as  a  thick  cord  on  deep  palpation  of  the  abdomen,  or  on 
rectal  or  vaginal  examination. 

The  second  kidney  may  be  enlarged,  painful  and  tender  from 
hypertrophy,  with  or  without  commencing  tuberculosis. 

There  is  progressive  loss  of  weight  and  lassitude. 

Course  and  prognosis. — The  course  is  slow,  and  remission 
of  the  symptoms  for  weeks  and.  even  months  may  be  observed.  The 
disease  gradually  advances  until  death  takes  place  some  years  (seven 
or  even  ten)  after  the  onset  of  the  symptoms.  The  disease  progresses 
until  the  kidney  is  completely  destroyed  ;  during  this  time  the  bladder 
and  the  second  kidney  become  affected.  Septic  infection  may  be 
superadded  either  by  hsematogenous  infection  or,  more  frequently,  by 
ascending  infection  from  septic  cystitis  caused  by  catheterization  or 
bladder  washing.  General  tuberculosis  rarely  follows.  Death  takes 
place  from  anuria  when  both  kidneys  are  invaded,  or  from  exhaustion 
due  to  septic  infection. 

Diagnosis. — The  diagnosis  can  usually  be  made  by  the  discovery 
of  tubercle  bacilli  with  pus  or  blood  in  the  urine,  but  when  the  ureter 
is  completely  blocked  no  changes  may  be  observed  in  the  urine.  In 
doubtful    cases  von  Pirquet's  and   Calmette's  tests   may  be  useful. 


830  THE   KIDNEY 

It  is  necessary  to  localize  the  disease  to  the  kidney  and  to  ascertain 
which  kidney  is  affected.  The  presence  of  symptoms  such  as  pain 
and  enlargement  of  the  kidney  is  not  always  reliable,  for  a  hyper- 
trophied  healthy  kidney  may  be  enlarged  and  ache,  while,  a  kidney 
destroyed  by  tubercle  may  not  be  palpable,  painful,  or  tender. 

On  cystoscopy  general  cystitis  without  typical  tuberculous  appear- 
ances may  be  found,  or  there  may  be  tubercles  or  ulceration  of  the 
vesical  mucous  membrane  or  a  collection  of  tiny  cysts  grouped  around 
one  ureteric  orifice.  The  orifice  may  be  open,  trumpet-shaped,  and 
extensively  ulcerated.  In  old-standing  tuberculosis  of  the  kidney  the 
ureteric  orifice  may  be  dragged  upwards  and  outwards,  and  appear 
like  a  tunnel  (Fenwick). 

The  urine  of  each  kidney  should  be  obtained  by  means  of  the  ure- 
teric catheter  and  examined  for  tubercle  bacilli,  pus,  blood  casts,  etc. 

Treatment.  1.  Tuberculin. — Amelioration  of  symptoms,  and 
in  some  cases  disappearance  of  pus  and  tubercle  bacilli  from  the  urine, 
may  be  observed,  but  recurrence  of  the  symptoms  may  take  place 
after  some  months  or  years.  Tuberculin  treatment  is  recommended  in 
— (a)  cases  of  unilateral  renal  tuberculosis  where  nephrectomy  has 
been  refused,  (b)  vesical  tuberculosis  after  nephrectomy,  (c)  bilateral 
renal  tuberculosis,  (d)  renal  with  active  extra-urinary  tuberculosis,  and 
(e)  renal  tuberculosis  in  children,  on  account  of  the  great  frequency  of 
bilateral  disease. 

2.  Climatic  and  medicinal. — A  warm  equable  climate  is  most 
suitable  (Egypt,  Morocco,  South  Africa).  Nourishing  diet,  with  plenty 
of  milk  and  fats,  should  be  recommended.  Urotropin  is  unnecessary 
if  no  septic  infection  be  present,  and  it  may  irritate  the  hypersensitive 
bladder.  Sandalwood  oil  soothes  the  vesical  irritation.  Washing 
the  bladder  is  useless  therapeutically,  and  involves  great  danger  of 
introducing  sepsis. 

3.  Operative.  Nephrectomy. — Nephrectomy  in  the  early  stage  of 
renal  tuberculosis  is  the  only  method  by  which  a  cure  can  be  assured, 
and  the  operation  is  indicated  whenever  the  diagnosis  of  unilateral 
renal  tuberculosis  is  made. 

Nephrectomy  is  contra-indicated  in — (i)  Bilateral  renal  tuberculosis  ; 
but  nephrectomy  of  the  more  advanced  organ  is  sometimes  advocated 
to  diminish  the  toxaemia. 

(ii)  Non-tuberculous  nephritis  of  the  second  kidney  ;.  but  if  the 
tests  for  the  function  of  this  kidney  be  satisfactory,  nephrectomy 
should  be  performed. 

(iii)  Tuberculous  lesions  of  the  bladder  ;  although  these  do  not 
contra-indicate  nephrectomy  if  the  second  kidney  can  be  proved 
healthy.  After  nephrectomy  the  cystitis  either  subsides  spontaneously 
or  disappears  under  tuberculin. 


RENAL   TUBERCULOSIS     SYPHILIS  831 

(iv)  Tuberculous  lesions  of  other  organs  :    bu1  obsolete  tuberculous 

foci  such  as  spinal  curvature,  ankylosed  joints,  healed  tuberculous 
disease  of  bones,  etc.,  do  no1  contra-indicate  nephrectomy.     Moreover, 

in  active  but  limited  tuberculous  disease  of  the  genital  organs,  nephrec- 
tomy may  be  performed.  In  active  disease  of  t  be  Lungs  or  ol  her  organs, 
nephrectomy   is  contra-indicated. 

(v)  A  generally  enfeebled  state  of  the  patient. 

The  following  procedures  may  he  carried  out  in  regard  to  the  ureter  : 
(i)  The  upper  end  may  be  fixed  in  the  lumbar  wound.  This  usually 
leads  to  tuberculous  infection  of  the  wound,  and  is  not  recommended, 
(ii)  The  ureter  may  be  ligatured,  cauterized,  and  dropped  into  the 
retroperitoneal  space.  The  ureteral  disease  usually  subsides  and  gives 
no  further  trouble,  but  occasionally  cyst  it  is  is  kept  up.  (iii)  The  ureter 
is  excised.  This  is  done  at  the  time  of  the  nephrectomy  by  prolonging 
the  incision.  The  ureter  is  stripped  from  the  peritoneum  and  followed 
into  the  pelvis,  where  it  is  ligatured  and  cut  across.  Some  inches  of 
the  tube  usually  remain  and  give  rise  to  no  trouble.  Kelly  suggests 
removing  the  lower  end  through  the  vagina  with  a  portion  of  the 
bladder  wall. 

Results  of  nephrectomy  for  primary  tuberculosis. — Brongersma  has 
shown  an  immediate  mortality  of  7T8  per  cent,  in  513  cases  of  nephrec- 
tomy by  ten  surgeons.  Where  the  modern  methods  of  diagnosis  were 
used  to  exclude  unsuitable  cases  the  mortality  fell  to  2'85  per  cent. 
There  is  a  risk,  amounting  to  10'6  per  cent.,  of  the  patient  dying  of 
tuberculosis  during  the  first  two  years,  and  a  risk  of  3T2  per  cent, 
of  a  fatal  result  from  tuberculosis  after  that. 

Nephrotomy. — This  is  a  preliminary  or  a  palliative  operation  when 
the  patient  is  much  enfeebled  from  toxaemia,  and  very  rarely  for  great 
pain  or  severe  haemorrhage. 

SYPHILIS    OF    THE    KIDXEY 

Nephritis  due  to  secondary  syphilis  is  rare,  and  always  bilateral.  In 
slight  cases  there  is  a  trace  of  albumin  in  the  urine  and  slightly  marked 
oedema.  In  severe  cases  there  is  oliguria,  pronounced  albuminuria,  with 
epithelial  casts  and  a  few  leucocytes  in  the  urine,  nausea,  vomiting,  anasarca, 
and  eventually  uraemia,  and  in  such  cases  interstitial  nepluitis  with  changes 
in  the  glomeruli  and  blood-vessels  are  usually  found. 

Tertiary  syphilis  may  give  rise  to  subacute  or  chronic  interstitial  nephritis, 
or  less  frequently  a  parenchymatous  nephritis.  The  disease  may  be  unilateral, 
and  may  affect  only  one  part  of  the  kidney.  Scarring  of  the  kidney  is  some- 
times found.  Gummata  are  single  or  multiple.  When  a  large  gumma  is 
present  the  kidney  is  enlarged,  hard,  and  irregular.  Such  kidneys  have  been 
removed  for  malignant  growth  or  tuberculous  disease.  Amyloid  degeneration 
may  occur  in  tertiary  syphilis.  Congenital  syphilis  may  atfect  the  kidney 
during  foetal  life,  and.  as  Stoerk  has  shown,  cause  arrest  or  delay  of  develop- 
ment, so  that  at  birth  the  outer  layer  of  the  cortex  contains  imperfectly 
developed  tubules  and  glomeruli.     During  infancy  and  childhood  acute  or 


832  THE    KIDNEY 

chronic  interstitial  nephritis  is  the  usual  form  of  the  disease.  This  condition 
iis  usually  bilateral,  but  one  kidney  or  a  part  of  a  kidney  may  be  affected. 
Treatment. — The  diet  and  general  management  of  these  cases  differ 
in  no  way  from  those  of  other  forms  of  nephritis.  Mercury  should  be  given 
in  small  doses  and  with  caution,  and  in  tertiary  !esions  it  should  be  combined 
with  iodides. 

BILHARZIOSIS    OF   THE    KIDNEY   AND    URETER 

Bilharzial  lesions  of  the  kidney  are  very  rare.  Ova  have  been  found  in 
the  renal  pelvis  and  parenchyma  in  cases  of  advanced  pyelonephritis  and 
interstitial  nephritis,  and  in  subcapsular  cysts ;  they  may  form  calculous 
nuclei.  In  the  pelvis  there  are  haemorrhages  and  ulceration.  The  mucous 
membrane  of  the  pelvis  is  covered  with  prominent  grey-yellow  plaques  formed 
by  blood  pigment,  uric-acid  crystals,  and  ova. 

The  lower  end  of  the  ureter  is  most  frequently  affected,  but  the  whole 
duct  may  be  involved.  The  lumen  may  be  contracted  and  obliterated,  and 
dilatation  of  the  ureter  and  hydronephrosis  results. 

ACTINOMYCOSIS    OF   THE    KIDNEY 
Renal  actinomycosis  presents  the  general  characteristics  of  the  disease 
(see  Vol.  I.,  pp.  873-9). 

RENAL   CALCULUS 

Stones  formed  in  the  kidney  may  remain  lodged  in  a  calyx  or  in 
the  pelvis,  or  they  may  pass  down  the  ureter  and  either  become 
arrested  in  the  duct  or  pass  into  the  bladder. 

Etiology. — A  urinary  calculus  is  an  agglomeration  of  crystals 
held  together  by  a  cement  substance.  The  crystalline  element  is 
produced  by  the  precipitation  of  certain  salts  as-  a  result  of  their 
excess,  or  of  changes  in  reaction,  or  as  a  consequence  of  bacterial 
action.  In  this  way  crystalline  forms  of  phosphates,  oxalate  of  lime, 
and  uric  acid  are  deposited  in  the  urine. 

In  infants,  masses  composed  of  urates  and  uric  acid  are  frequently 
found  in  the  convoluted  tubules  soon  after  birth.  These  disappear 
when  the  flow  of  urine  is  fully  established,  but  may  remain  to  form 
the  nucleus  of  a  true  calculus. 

The  presence  of  a  colloid  cement  substance  is  the  second  essential 
factor.  The  colloid  bodies  of  the  normal  urine  (mucin,  urochrome) 
are  "  reversible  " — that  is,  they  may  be  dissolved  again — and  therefore 
they  do  not  form  a  calculus  even  when  crystals  are  deposited  from 
the  urine.  An  "  irreversible  "  colloid — that  is,  one  which  is  insoluble 
when  once  precipitated  (e.g.  fibrin) — is  necessary. 

The  average  age  at  which  renal  calculi  occur  is  38  years  (Watson). 
Operations  for  renal  calculus  are  rarely  necessary  in  children  under 
10.  Men  are  more  frequently  affected  than  women  ;  the  kidneys 
are  equally  affected.  In  the  early  stage  the  disease  is  unilateral, 
but  later  it  is  bilateral  in  over  50  per  cent,  of  cases. 

Heredity,  sedentary  habits,  certain  focds,  and  hard  drinking-water 


Multiple  calculi  of  the  kidney. 


Plate  104. 


RENAL   CALCULI  S  833 

arc  important   etiological   Eaotors.    Calculous  is  common   in 

India  both  in  Europeans  and  in  natives.  In  Europe  calculus  1-  spe- 
cially prevalent  in  Centra]  Russia,  Bungary,  Holland,  Italy,  Northern 
Germany,  Western  Prance,  and  the  eastern  counties  of  England. 

Structure    and     chemical    composition.-- Th*-    calculus 
consists  of  .1  centra]  nucleus  surrounded  by  laminsa  f»f  varying  com- 
position.   The  nucleus  generally  consists  of  orate  of  ammonia  in  infai 
of  urn-  acid  in  adults,  and  of  oxalate  of  lime  after  the  age  of  40.     In 
ran-  fragment  of  blood  clot  forms  the  nucleus,  and  the  ova  of 

nilharzia  have  been  found  in  countries  where  bilharziosis  is  rife,  i 
quentlv  there  are  alternate  layers  of  uric  acid  and  oxalate  of  lime  or 
triple  phosphates  or  calcium  carbonate.  The  following  substance.- 
enter  into  the  composition  of  renal  calculi,  viz.  uric  acid,  ammonium  and 
sodium  urate,  calcium  oxalate,  calcium  phosphate,  calcium  carbonate, 
ammonium  and  magnesium  phosphate,  cystin,  xanthin,  indigo,  blood. 

Calculi  are  rarely  composed  of  a  single  salt.  Phosphatic  deposits 
take  place  where  the  urine  becomes  alkaline.  Oxalate  of  lime  is 
much  the  most  frequent  component,  44  per  cent.,  and  uric  acid  next, 
2l*  per  cent.  (Morris).  Oxalate-of-lime  calculi  are  usuallv  single,  very 
hard,  dark-brown  or  black,  with  a  nodulated  surface,  or  covered  with 
fine  or  coarse  clear  crystalline  spicules,  and  are  laminated  on  section. 
Sometimes  they  form  small  multiple  seed-like  bodies.  Uric-acid 
calculi  are  single  or  multiple,  hard,  smooth,  sometimes  highly  polished, 
and  yellow  or  red-brown  in  colour.  Ammonium  and  sodium-urate 
calculi  occur  in  children,  and  are  small,  soft,  friable,  and  pale  fawn 
in  colour.  Calcium-phosphate  calculi  are  greyish-white,  hard,  with  irre- 
gular and  sometimes  crystalline  surface,  and  are  found  in  neutral  or 
slightly  alkaline  urine.  Calculi  of  mixed  phosphates  (fusible  calculus) 
are  whitish-grey,  non-laminated,  mortar-like  friable  masses,  which  grow 
rapidly  in  alkaline  urine.  Cystin  calculi  are  yellow,  smooth,  and  soft, 
assume  a  greenish  waxy  appearance  after  removal,  and  have  a  radiating 
structure.  Xanthin  calculi  form  smooth,  hard,  reddish  or  cinnamon- 
coloured  stones.  Indigo  calculi  are  blue-black  with  a  grev,  polished 
surface,  and  leave  a  blue  mark  on  white  paper.  Blood  or  fibrin 
calculi  form  faceted  masses  of  putty-like  consistence,  and  have  a 
brown  colour  and  laminated  structure. 

The  majority  of  calculi  removed  by  operation  are  single,  but 
multiple  calculi  are  not  uncommon.  (Fig.  545.)  Small  calculi  mav 
form  in  a  pouch  in  the  pelvis  or  a  calyx,  and  pass  down  the  ureter 
at  intervals  for  many  years.  Larger  calculi  are  rounded  or  oval,  and 
may  be  freely  movable  in  the  pelvis  or  firmly  fixed.  Large  calculi 
are  branched,  and  the  branches  fill  the  calyces.  (Plate  104.)  Calculi 
of  l£  lb.  (Shield)  and  3  lb.  (Le  Dentu)  have  been  found.  A  calculus 
has  very  rarely  been  found  embedded  in  the  substance  of  the  kidnev. 
3  b 


;34 


THE   KIDNKY 


Changes  in  the  kidney.— When  a  large  stone  is  present  the 
kidney  is  destroyed  by  pressure  and  there  is  extensive  perinephritis. 
Complete  or  partial  hydronephrosis  or  pyonephrosis  may  develop. 

Symptoms.— Occasionally   a    calculus    lies   quiescent    for  many 

years,     Persistent  cystitis  may  he  present,  but  no  symptoms  of  renal 

I  ses  there  are  signs  of  profound  toxaemia  due  to 

ryelonephritis,  without  symptoms  of  stone.     The  cardinal  symptoms 

ire   pain   (70   per   cent.)   and   hematuria.     Pain  may  be  fixed  renal 


Fig.  545. — Calculi  removed  from  one  kidney. 


pain  or  renal  colic.  The  former  is  a  constant  ache  of  varying  inten- 
sity, increased  by  movement  and  relieved  by  rest.  In  walking,  the 
body  may  be  inclined  to  the  diseased  side,  and  when  lying  the  thigh 
is  flexed.  The  greatest  pain  is  produced  by  a  small  round  or  oval, 
rough,  crystalline  stone  free  in  the  renal  pelvis. 

Renal  colic  commences  over  the  kidney,  and  radiates  along  the 
line  of  the  ureter  to  the  external  abdominal  ring  or  into  the  testicle, 
which  is  retracted,  or  it  may  shoot  along  the  urethra  to  the  tip  of 
the  penis.  hi  a  severe  attack  the  patient  rolls  in  agony,  the  face  is 
pale,  the  skin  clammy  and  sweating,  and  vomiting  occurs.     The  abdo- 


RENAL   GALCUl  835 

minal  muscles  are  rigid  and  the  thigh  flexed.    There  may  be  u 

to  micturate,  bul   anuria   may  be  present.     If  unrelieved   bj 
treatment,  the  attack  lasts   for  one  oi  ad  then  1 

suddenly  or  gradually.     Alter  an  intervals  quantity  oi  blood-si 
urine  may  \><-  passed.     Referred  p. mm  may  be  observed  is  the  testicle, 
labium,  thigh,  leg,  sole  oi  the  foot,  ot  heel.    There  may  I"-  bladder 
jKiin  and  irritation  when  the  bladder  is  healthy.     Pain  may  i 
to  the  second  kidney,  l>ut  if  that  organ  is  healthy  the  referred  pain  is 
always  accompanied  by  pain  in  the  diseased  kidney. 

II  iinatniia   is  present    in   less  than  half  t  [t  is  micro- 

scopic,  moderate,   or    copious,    and    is    intimate!  ted    with 

movement  and  exertion. 

Pyuria  may  be  moderate,  but  if  there  is  pyonephrosis  it  is 
abundant  and  intermittent. 

The  urine  is  usually  acid,  rarely  alkaline  and  decomposing.  It 
may  contain  hyaline  easts,  crystals  of  calcium  oxalate,  or  uric  acid. 
Phosphaturia  may  be  present. 

Polyuria  is  a  late  symptom,  and  calculous  anuria  may  supervene. 
The  kidney  is  occasionally  tender,  and  the  abdominal  muscles  rigid. 
An  abdominal  tumour  may  be  formed,  and  rarely  a  large  collection 
of  -tones  is  felt  as  a  hard,  irregular,  craggy,  grating  in 

On     cystoscopic     examination    there     is     unilateral     hematuria 
or    pyuria.     Elongation  of   the    ureteric     orifice    and    inflammation 
surrounding  the  opening   may  be    observed.     Radiography 
calculus  shadow. 

Course  and  complications. — As  the  stone  increase* 
size  the  pain  diminishes.  Renal  calculus  may  exist  for  years  without 
causing  grave  inconvenience.  The  complications  that  may  occur  are 
— (1)  migration  with  renal  colic.  (2)  obstruction  with  calculous  hydro- 
nephrosis or  calculous  anuria.  (3)  infection  causing  pyelitis,  pyelo- 
nephritis, pyonephrosis,  perinephritis,  and  perinephritic  abscess. 

Diagnosis. — The  most  important  symptoms  are  the  severity  of 
the  pain  and  the  effect  on  it  and  on  hsematuria  of  movement  and 
jarring.  The  previous  passage  of  a  calculus  and  the  presence  of 
numerous  crystals  in  the  urine  are  important. 

Apart  from  stone,  renal  colic  may  result  from  undue  mobility  of 
the  kidney,  from  ureteritis,  or  from  the  passage  of  blood  clot,  debris, 
or  large  quantities  of  uric-acid  or  oxalate  crystals.  Renal  pain  may 
be  caused  by  nephritis,  and  simulated  by  the  crises  of  locomotor 
ataxy,  by  hysteria,  by  osteoarthritis  of  the  lumbar  vertebra?,  and  by 
hepatic  colic. 

The  final  test  is  the  X-ray  examination. 

In  cases  where  cystitis  is  the  prominent  feature  the  cystoscope  will 
show  a  purulent  efflux  on  one  side,  which  will  lead  to  a  diagnc- 


THE    KIDNEY 

Before   operation  is  undertaken  it   is    I  rtain  the 

ce  and  health  of  the  second  kidney  by  c  .   chromo- 

and  examination  of  the  urine  drawn  from  the  ureter  of 
ttd  kidney  by  the  nietezal  catheter. 

Prophylactic    treatment. — This    <  in    the  treatment 

of  oxaluria,  phosphaturia,  and  lithiasis.  and  the  removal  of  local  con- 
ditions which  may  formation  erf  Btone,  viz.  urinary  infection 
and  obstruction. 

Treatment  of  symptoms.  Renal  colic. —  The  patient  u 
placed  in  a  hot  bath  and  a  hypodermic  injection  of  morphine  sul- 
phate (-j-  to  |  gr.)  with  atropine  sulphate  {.J,^  gr.)  administered.  Hot 
fomentations  or  poultices  are  applied  over  the  loin  and  abdomen. 
Very  rarely  it  is  found  necessary  to  keep  the  patient  lightly  under 
the  influence  of  chloroform  for  an  hour  or  more. 

//.  nal  JuBtnatuf4a.—T\  isionally  severe  after  a  fall  or  blow. 

The  patient  should  rest  in  bed  with  an  ice-bag  over  the  kidney.  A 
hypodermic  injection  of  morphia  should  be  given,  and  10  to  15  gr. 
of  calcium  lactate  administered  by  mouth  every  four  hours.  For 
persistent  and  severe  hsematuria,  operation  is  necessary. 

Calculous  anuria.     [See  later.) 

Operative  treatment.  — Whi -n    the    di   _  is    made    the 

old,  unless  d  eptional  cases,  be   removed  without 

delay. 

i  ses  of  extensive  bilateral  calculous  disease  with  progressive  renal 
failure  or  with  widespread  sepsis,  and  cases  in  which  small  calculi 
are  frequently  passed  and  the  X-rays  do  not  show  a  large  single 
shadow  or  a  collection  of  small  shadows  in  the  kidney,  are  unsuitable 
for  operation. 

1.  Nephrolithotomy. — The  kidney  is  exposed  by  a  lumbar  in- 
cision, and  the  stone  removed  by  incision  through  the  convex  border. 
The  pelvis  and  ureter  are  also  examined. 

The  nephrotomy  wound  is  closed  with  catgut  in  rounded  needles. 
,  there  is  sepsis  and  dilatation  of  the  kidney  a  medium-sized 
drain  should  be  placed  in  the  kidney  wound.  The  dangers  of  nephro- 
lithotomy are  haemorrhage  and  septic  infection.  Postoperative  haemor- 
rhage is  usually  due  to  Bepsis  r,r  to  tearing  out  of  ligatures.  When 
slight  it  may  be  controlled  by  morphia  and  calcium  lactate  ;  but 
if  copious  and  persistent,  exposure  and  packing  of  the  kidney  may 
be  necessary,  and  sometimes  nephrectomy  is  required. 

Results. — In  aseptic  kidneys,  when  dilatation  is  not  present,  the 
mortality  is  2'2  per  cent  (Watson).  In  infected  cases  the  death-rate 
is  as  high  as  20-3  pfjr  cent.  (Schmieden).  In  infected  cases  a  fistula 
may  persist,  and  this  may  also  result  from  calculi  having  been  left 
in  the  kidney,  or  from  ureteral  or  pelvic  obstruction.     Fistulse  occur 


RENAL  CALCULUS  837 

in  8*1  per  cent,  of  all  cases  (Watson)  and  is  22*2  per  cent,  of  Infected 
oases  (Schmieden). 

2.  Pyelolithotomy.  The  calculus  is  removed  through  an  in- 
cision in  the  pelvis  of  the  kidney.  The  kidney  is  drawn  OUl  "I  the 
lumbal  wound  and  tinned  forwards  and  upwards,  a  Longitudinal 
incision  made  in  the  wall  of  the  pelvis,  and  the  stone  removed,  The 
edgea  of  the  opening  are  then  stitched  with  fine  catgut.  I  turn  down 
1  flap  of  kidney  capsule  and  cover  the  closed  incision  to  prevent 
leakage.  Mayo  recommends  a  flap  of  fatty  tissue  Eor  the  same 
purpose. 

Results. — The  mortality  in  54  uncomplicated  cases  was  111  per 
cent.,  and  a  fistula  remained  in  222  per  cent.  (Schmieden). 

3.  Nephrectomy — Primary  nephrectomy  is  rarely  performed  for 
calculus.  It  may  be  necessary — (1)  in  severe  uncontrollable  hsemor- 
rhage  during  nephrolithotomy,  (2)  when  the  kidney  is  atrophied  or 
destroyed  by  suppuration,  (3)  when  calculi  are  so  numerous  and 
large  that  they  cannot  be  removed  without  destroying  the  kidney, 
(4)  when  a  malignant  growth  is  present. 

Secondary  nephrectomy  may  be  called  for  in — (1)  urinary  fistula 
causing  great  discomfort  and  irremediable  by  other  means,  (2)  re- 
currence of  stone  with  atrophy  of  the  kidney,  (3)  prolonged  renal 
suppuration. 

Results. — Primary  nephrectomy  for  calculus  has  a  mortality  of 
30*1  per  cent.,  and  secondary  nephrectomy  181  per  cent.  (Watson). 

Bilateral  calculi  and  calculi  in  a  solitary  kidney. 
— It  is  unwise  to  remove  the  stones  from  both  kidneys  at  the  same 
operation.  The  less  affected  kidney  should  first  be  operated  upon, 
in  case  it  may  become  necessary  to  perform  nephrectomy  on  the 
second  kidney  later. 

Statistics  show  a  mortality  of  35  per  cent,  in  operations  on  double 
calculi  (Kiister).  In  operating  on  a  solitary  kidney,  pyelolithotomy 
should  be  preferred  to  nephrolithotomy. 

CALCULOUS   ANURIA 

Calculous  anuria  occurs  usually  in  men  between  the  ages  of  40 
and  60.  The  calculus  is  small  and  single,  and  the  exciting  cause  is 
violent    exercise,   shaking,   or  jarring. 

Pathology. — There  is  usually  only  one  calculus,  which  is 
arrested  at  the  upper  end  of  the  ureter  (61  per  cent.),  the  lower  part 
(28  per  cent.),  or  the  middle  (11  per  cent.).  The  obstructed  kidney  is 
large  and  deeply  congested  with  ecchymoses  on  the  surface,  and  the 
pelvis  contains  2  or  3  drachnis  of  blood-stained  urine  under  con- 
siderable tension.  The  second  kidney  is  always  the  scat  of  organic 
disease,   usually  interstitial  nephritis.     In   a  few   eases  this  ureter  is 


838  THE    KIDNEY 

also  blocked  by  calculus,  and  rarely  there  is  congenital  absence  of  the 
second  kidney. 

The  suppression  on  the  affected  side  is  due  to  sudden,  complete 
obstruction  by  the  impacted  calculus  ;  that  on  the  opposite  side  is 
usually  reflex. 

The  following  conditions  may  be  found  : — 

1.  The  ureter  of  a  single  functional  kidney  blocked  by  stone  ;  the 
second  kidney  absent,  atrophied,  or  completely  destroyed  by  disease. 

2.  The  ureters  of  two  functional  kidneys  simultaneously  blocked 
by  stones. 

3.  The  ureter  of  one  functional  kidney  blocked  by  stone,  and 
the  function  of  the  second  kidney,  which  is  diseased,  suppressed  by 
reflex  influences. 

Symptoms. — The  kidney  on  the  recently  affected  side  is  fre- 
quently enlarged  and  tender,  and  there  is  rigidity  of  the  abdominal 
muscles,  especially  marked  on  this  side.  There  may  be  tenderness 
per  rectum  along  the  line  of  the  ureter  and  of  the  lower  end  of 
the  ureters.  The  calculus  can  sometimes  be  detected  by  the  finger 
in  the  rectum  or  vagina.  On  cystoscopic  examination  the  ureteric 
orifice  on  the  recently  diseased  side  is  congested  or  even  ecchymosed. 

A  severe  attack  of  ureteric  colic  usually  precedes  the  onset  of  the 
anuria,  but  suppression  may  supervene  without  pain  or  other  symptom. 

The  course  of  calculous  anuria  is  divided  into  two  stages  : 

1.  A  period  of  tolerance. — The  average  duration  of  this  stage 
is  five  or  six  days,  and  the  longest  sixteen  days.  The  anuria  may  be 
absolute,  but  frequently  a  little  urine  is  secreted  or  there  are  one  or 
more  intervals  of  copious  polyuria. 

After  some  days,  digestive  disturbances  appear  and  the  appetite 
fails.  There  are  nausea,  constipation  and  flatulence  sleeplessness, 
irritability,  headache,  and  lassitude. 

2.  A  period  of  intoxication. — This  stage  commences  about 
the  fifth  or  seventh  day.  Drowsiness  and,  eventually,  hallucinations 
and  muttering  delirium  supervene.  The  pupils  are  contracted  and 
twitchings  of  the  muscles  occur,  but  convulsions  are  absent.  There 
may  be  inability  to  move  one  or  both  legs,  and  the  knee  jerks  are 
slow  or  abolished.  The  pulse  and  respiration  are  slow  and  irregular, 
and  eventually  Cheyne-Stokes  respiration  develops.  The  temperature 
is  subnormal.  (Edema  is  usually  absent.  Hiccup  and  vomiting  are 
frequent  symptoms.  The  bowels  are  constipated.  The  patient  dies 
either  during  an  attack  of  dyspnoea  or  from  increasing  coma  and 
gradual   heart  failure. 

Diagnosis.  1.  What  is  the  cause  of  the  anuria? — Previous 
attacks  of  colic,  and  the  history  of  calculi,  or  the  detection  of  a  cal- 
culus in  the  ureter  by  the  finger  in  the   rectum  or  by  radiography 


CALCULOUS   ANURIA  830 

and  cystoscopy,  may  aid  diagnosis.    The  absence  oi   fever  excludes 
pyelonephritis  as  a  oause. 

Other  forma  of  obstruction,  Buch  as  bladder   01    pelvic  growths, 
must    be    excluded.     The    history  and  examination  readily  exclude 
anuria    resulting    from    advanced    tuberculous    disease,    porj 
disease,   or  chronic   nephritis,   and   the   Bymptoms   are   unlike  those 
oi  acute  nephritis. 

2.  Which  side  is  affected  ?—  When  there  is  a  history  <>f 
bilateral  ureteral  colic  the  side  oi  the  recent  pain  is  that  of  the 
active  kidney  and  recently  blocked  ureter.  The  abdominal  muscles 
are  rigid  on  the  affected  side.  The  kidney  is  tender  and  may  be 
enlarged,  and  the  ureter  also  is  tender. 

Extensive  radiographic  shadows  in  one  kidney  show  that  this 
organ  was  previously  destroyed,  and  a  shadow  in  the  line  of  the 
opposite  ureter  would  indicate  and  localize  the  cause  of  the  anuria. 

Catheterization  of  the  ureter  may  demonstrate  the  affected  Bide 
and  the  position  of  the  stone. 

Prognosis. — Death  occurs  in  71  per  cent,  of  unoperated  cases 
(Legueu),  usually  on  the  tenth  or  twelfth  day.  In  cases  which  recover 
spontaneously,  relief  is  usually  obtained  on  the  fifth  to  the  tenth  day. 

Treatment. — Operation  should  be  performed  at  the  earliest  pos- 
sible moment  in  all  cases.  The  mortality  rises  each  day  the  operation 
is  delayed,  from  25  per  cent,  before  the  fourth  day  to  42  per  cent. 
before  the  sixth  day.  In  addition,  other  means  should  be  adopted 
to  re-establish  the  secretion.  Diuretics  such  as  Contrexeville  water. 
tea,  theocin  sodium  acetate  (-4  gr.  every  four  hours)  combined  with 
digitalis,  should  be  given.  Two  pints  of  normal  saline  or  a  23;  per  cent. 
solution  of  glucose  should  be  infused  into  a  vein  during  or  after  the 
operation.  A  purge  should  be  administered,  and  every  means  taken 
by  hot  packs  and  vapour  baths  to  obtain  a  free  action  of  the  skin. 
The  nature  of  the  operation  depends  on  the  position  of  the  obstructing 
stone,  the  possibility  of  localizing  it,  and  the  ease  or  difficulty  with 
which  it  can  be  removed.  It  is  more  important  to  relieve  the  obstruc- 
tion quickly  than  to  remove  the  calculus.  Nephrotomy  should  be 
performed  when  the  stone  is  localized  to  the  pelvis,  when  no  accurate 
localization  has  been  possible,  or  when  it  has  been  localized  to  the 
ureter  but  its  position  would  necessitate  a  prolonged  operation  for 
its  removal.  If  the  stone  is  found  it  should  be  removed  ;  if  it  is  not 
found  a  large  drainage-tube  is  placed  in  the  renal  pelvis  and  the 
kidney  wound  lightly  packed  with  gauze.  The  obstructing  calculus 
can  be  removed  later. 

Pyelotomy  or  ureterotomy  may  be  substituted  for  nephrotomy 
when  the  stone  is  readily  accessible. 

The  mortality  of  cases  treated  by  operation  is    10-"»  per  cent. 


S4o  THE    URETER 


THE    URETER 

Anatomy. — The  ureter  narrows  at  its  junction  with  the  renal  pelvis 
near  the  lower  pole  of  the  kidney,  again  at  the  pelvic  brim,  and  again  at 
its  entrance  into  the  bladder.  As  seen  in  radiography,  the  upper  end  of 
the  ureter  lies  at  the  tip  of  the  transverse  process  of  the  2nd  lumbar 
vertebra ;  thence  the  duct  descends  across  the  tip  of  the  transverse  process 
of  the  3rd  and  the  transverse  processes  of  the  4th  and  5th  lumbar  vertebrae, 
and  passes  vertically  across  the  pelvic  brim,  internally  to  the  sacro-iliac 
synchondrosis.  It  then  curves  outwards  across  the  outer  border  of  the 
sacrum  and  ischial  spine,  and  turns  inwards  above  the  shadow  thrown  by 
the  horizontal  ramus  of  the  pubic  bone. 

The  ureter  is  adherent  to  the  peritoneum,  and,  when  the  membrane  is 
raised,  remains  attached  to  it.  In  the  male  its  terminal  extravesical  portion 
is  crossed  by  the  vas  deferens.  In  the  female  it  crosses  beneath  the  broad 
ligament,  and  alongside  and  then  in  front  of  the  lateral  fornix  of  the  vagina 
and  the  cervix  uteri.  Here  it  passes  below  and  behind  the  uterine  artery, 
and  is  surrounded  by  a  dense  venous  plexus. 

The  intramural  portion  is  J  in.  long,  and  passes  very  obliquely  through 
the  bladder.  The  ureteric  orifices  open  on  the  bladder  base,  J  in.  to  1  in. 
apart. 

Examination. — On  deep  palpation,  in  a  favourable  subject,  a 
thickened  ureter  can  be  felt  lying  alongside  the  vertebral  column. 

On  rectal  palpation,  in  the  male  the  ureter  is  felt  above  and  outside 
the  base  of  the  prostate,  and  in  the  female  it  may  be  felt  in  the  anterior  wall 
at  the  junction  of  the  middle  and  upper  thirds  of  the  vagina. 

The  appearance,  movements,  and  efflux  of  the  vesical  orifice  of  the  ureter 
are  examined  by  cystoscopy  or  by  Kelly's  tube. 

The  urine  of  each  kidney  is  obtained  by  ureteral  catheterization  (p.  780). 

The  X-rays  sometimes  show  the  shadow  of  a  much  dilated  or  greatly 
thickened  ureter.  Calculi  impacted  in  the  ureter  throw  a  radiographic  shadow 
in  the  line  of  the  duct.    (Plates  38-41,  Vol.  I.) 

It  is  sometimes  necessary  to  pass  an  opaque  bougie  up  the  ureter  in  order 
to  define  the  line  of  the  duct  and  the  position  of  a  doubtful  shadow.  The 
ureter  may  be  sounded  by  passing  a  ureteric  catheter  or  a  wax-tipped  bougie. 

PROLAPSE 

There  may  be  unilateral  or  bilateral  prolapse  of  the  whole  thickness  of 
the  ureteral  wall  or  of  the  mucous  membrane  alone.  A  globular  or  sausage- 
shaped  cyst  is  formed,  varying  in  size  from  a  pea  to  a  walnut  or  larger.  The 
wall  consists  of  a  double  layer  of  mucous  membrane,  and  at  the  summit  of 
the  swelling  the  stenosed  ureteric  orifice  opens.  Calculi  are  sometimes  found 
in  the  sac.  The  condition  may  result  from  a  congenital  narrowing  of  the 
ureteric  orifice  or  an  acquired  stenosis  from  ureteritis.  The  symptoms  are 
irregular.  There  may  be  pain  in  the  kidney  or  ureter,  or  symptoms  of  vesical 
irritation  or  of  urethral  obstruction.  Occasionally  there  is  complete  retention. 
Attacks  of  hajmaturia  may  be  the  only  symptom.  The  cyst  may  appear 
at  the  external  meatus  in  the  female  subject.  The  cystoscope  shows  a  pink, 
semitranslucent,  globular  or  sausage-shaped  swelling  over  which  fine  blood- 
vessels course.  The  cyst  may  slowly  fill  and  slowly  collapse  under  observa- 
tion. Treatment  consists  in  cutting  off  the  pouch  at  its  base  with  scissors 
and  removing  any  calculi  that  are  present. 


INJUKIKS    AM)    WOl'NDS    OF    I'RKTKK  841 

INJURIES 

1.  Subcutaneous  [nji  totes  and  Penetrating  Wounds 

Injuries  of  this  aatore  are  rare,  The  peritoneum  is  aimultaneoualy  rup- 
tured in  8  per  cent  of  oases.  The  duel  is  injured  by  impacl  againsl  the 
transverse  process  of  a  lumbar  vertebra  or  by  overstretching.  Urine 
aooumulates  in  the  retroperitoneal  space  or  leaks  into  the  peritoneum. 

Symptoms.  There  are  pain  and  tenderness,  which  pass  off  in  a  few 
days  if  the  injury  is  uncomplicated.  A  swelling  appears  in  the  loin  in  a  few 
days  or  after  some  weeks.  It  is  rounded  or  elongated  and  well  defined,  and 
may  assume  a  large  size.  Suppuration  takes  place  and  the  temperature 
rises.  It  is  impossible  to  diagnose  between  a  rupture  of  the  ureter  and  rupture 
of  the  renal  pelvis.  A  urinary  fistula  follows  penetrating  wounds  of  the 
ureter.     The  prognosis  is  good  when  early  operation  is  performed. 

Treatment. — Operation  should  immediately  follow  diagnosis.  It  is 
difficult  to  find  the  end  of  the  ureter  when  it  is  completely  torn  across,  and  a 
catheter  should  be  passed  up  the  duct  from  the  bladder  before  commencing 
the  operation.  The  ends,  when  identified,  should  be  anastomosed.  Nephrec- 
tomy may  be  required  in  rare  cases  for  septic  complications,  or  for  the  cure 
of  intractable  fistula. 

2.  Surgical  Wounds 

Injury  to  the  ureter  is  occasionally  caused  by  forceps  during  delivery, 
but  more  frequently  occurs  during  pelvic  operations,  especially  on  the  ovaries 
and  uterus.  It  may  be  partly  or  completely  cut,  or  its  wall  or  blood  supply 
damaged,  so  that  it  sloughs  and  a  fistula  forms  after  some  days.  The  fistula 
may  open  in  the  vagina  or  in  the  cervix,  if  a  subtotal  excision  of  the  uterus 
has  been  performed,  or  it  may  open  at  the  abdominal  wound. 

Treatment. — When  the  ureter  has  been  partly  cut  or  lacerated  the 
edges  of  the  wound  should  be  sutured  with  fine  catgut. 

A  ureteral  catheter  should  be  retained  in  the  ureter  for  a  week.  A 
covering  of  areolar  tissue  or  even  of  peritoneum  greatly  assists  healing  of 
the  ureteral  wound.  An  irregular  tear  or  a  complete  laceration  is  better 
treated  by  resection  of  a  portion  of  the  tube,  followed  by  anastomosis  by 
one  of  the  following  methods : — 

1.  End-to-end  anastomosis. 

2.  End-to-end  anastomosis  with  invagination. 

3.  Anastomosis  by  means  of  a  button  or  a  tube  of  magnesium. 

4.  End-to-side  anastomosis  with  or  without  invagination. 

5.  Lateral  anastomosis. 

When  a  portion  of  the  ureter  has  been  torn  away,  one  of  the  following 
procedures  may  be  carried  out : — 

1.  Implantation  of  the  upper  part  of  the  ureter  into  the  bladder  (uretero- 

cysto-neostomy). 

2.  Uretero-ureteral  anastomosis,  the  torn  ureter  being  grafted  with  the 

sound  ureter. 

3.  Formation  of  a  cutaneous  fistula. 

4.  Implantation  into  the  intestine. 

5.  Immediate  nephrectomy. 

Nephrectomy  should,  if  possible,  be  avoided;  cystitis  is  frequently  present, 
and  thus  there  is  danger  of  ascending  pyelonephritis  of  the  remaining  kidney. 

Results. — In  60  cases  of  ureteral  anastomosis  there  were  43  complete 
recoveries,  9  recoveries  after  temporary  fistula,  and  8  deaths  (Alksne). 


S42  THE   URETER 

FISTULA 

Fistula  of  the  ureter  may  be  cutaneous  or  vaginal,  and  may  be 
congenital,  or  result  from  surgical  operation,  or  follow  parturition. 
On  the  vesical  side  of  the  fistula  there  is  usually  stenosis  of  the  ureter, 
and  above  the  fistula  the  ureter  and  kidney  are  frequently  dilated. 
Infection  of  the  fistula,  ureter,  and  kidney  invariably  occurs. 

When  the  ureter  is  completely  severed,  cystoscopy  shows  no  move- 
ment at  the  ureteric  orifice,  but  in  partial  division  rhythmic  contraction 
is  observed.  Methylene-blue  solution  injected  into  the  bladder  will 
escape  by  the  fistula  if  it  communicates  directly  with  the  bladder,  but 
does  not  escape  when  the  ureter  only  is  affected.  It  is  sometimes 
difficult  to  ascertain  which  ureter  is  fistulous.  This  information  is 
obtained  by  cystoscopy,  when  the  orifice  of  the  affected  ureter  is 
motionless  and  without  efflux,  and  the  subcutaneous  injection  of 
indigo-carmine  is  followed  by  a  coloured  efflux  from  the  healthy 
ureter  and  none  from  the  fistulous  ureter. 

The  position  of  the  fistula  is  ascertained  by  sounding  the  ureter 
with  an  opaque  bougie  and  obtaining  a  radiogram. 

Treatment. — The  introduction  of  a  catheter  en  demeure  is 
impossible  in  many  cases  on  account  of  the  stricture.  When  it  has 
been  practicable  the  result  has  not  been  permanently  satisfactory, 
the  stricture  recontracting  and  the  fistula  again  appearing. 

Several  methods  of  transplantation  of  the  ureter  have  been  tried. 
Exposure  of  the  upper  end  of  the  ureter  and  implantation  into  the 
bladder  is  occasionally  successful. 

Implantation  into  the  ceecum  or  sigmoid  has  been  practised  with 
an  operative  mortality  of  58  per  cent,  in  bilateral  implantation, 
and  of  29  per  cent,  in  unilateral  implantation.  Death  usually  occurs 
within  a  short  time  from  ascending  pyelo-nephritis. 

Plastic  operations  on  the  vagina  and  obliteration  of  the  vagina 
have  been  successful  in  a  few  cases. 

Nephrectomy  should  only  be  performed  after  other  methods  have 
failed. 

STOXE 

The  great  majority  of  stones  found  in  the  ureter  have  been  formed 
in  the  renal  pelvis.  Rarely  a  calculus  forms  around  a  foreign  body 
such  as  a  silk  stitch  (Fig.  546,  3).  Impaction  usually  takes  place  at 
the  outlet  of  the  renal  pelvis,  at  the  entrance  of  the  ureter  into  the 
bladder,  or  at  the  level  of  the  brim  of  the  bony  pelvis.  In  rare  cases 
the  position  of  the  calculus  varies  with  the  attitude  of  the  patient. 

There  is  usually  only  one  calculus  (90  per  cent.),  but  there  may  be 
two,  three,  or  as  many  as  twenty-seven.  Ureteral  calculi  are  bilateral 
in  only  3'6  per  cent,  of  cases. 


URETERIC   CALCULUS  843 

In  Bhape  they  resemble  a  date  01  a  oofiee  bean.  When  large  thej 
may  be  round  01  sausage-shaped.  Ureteral  calculi  weighing  816  gr. 
(Bloch),  803  gr.  (Carless),  and  780  gr.  (Federoft)  have  been  recorded. 
The  surface  may  be  smooth,  bossy,  <>r  Bpiculated.  (Rg.  546.) 
There  is  frequently  a  stricture  below  the  poinl  ol  impaction.  Ed 
old-standing  cases  the  ureter  above  the  calculus  is  dilated,  and  the 
kidney  hydronephrotic.    There  are  calculi  in  the  corresponding  kidney 


Fig.  546. — Collection  of  ureteric  calculi. 

i,  Calculi  passed  after  temporary  impaction  ;  2,  calculus  impacted  at  ureteric  orifice,  mush- 
room-shaped   portion  in  bladder  ;  3,  calculi  formed  on   silk  sutures  ;    4-8,  impacted   calculi 
removed  by  operation. 

in  13  per  cent,  of  eases.     Pyonephrosis  may  be  found  ;    sclerosis  and 
atrophy  of  the  kidney  are  rare. 

Symptoms. — When  the  calculus  passes  along  the  ureter  there 
is  an  attack  of  renal  colic,  repeated  at  frequent  or  at  long  intervals. 
The  pain  may  commence  at  a  spot  in  the  line  of  the  ureter  lower  than 
the  kidney,  and  it  may  remain  fixed  at  this  spot.  There  may  also 
be  fixed,  dull  aching  pain  over  some  part  of  the  ureter.  This  pain  is 
aggravated  by  movement  or  straining,  or  on  taking  diuretics.  The 
attacks  of  colic  may  be  frequent  and  severe  till  the  calculus  is  expelled 
into  the  bladder.  The  patient  frequently  feds  something  drop  into 
the  bladder,  and  the  pain  ceases.  After  some  hours  or  days  the  cal- 
culus is  discharged  from  the  urethra. 


S44  THE   URETER 

At  the  upper  part  of  the  ureter  the  symptoms  are  rarely  distinguish- 
able from  those  of  calculus  in  the  renal  pelvis.  "When  the  stone  lies 
just  outside  or  in  the  wall  of  the  bladder,  symptoms  of  bladder  irritation 
become  prominent,  and  there  is  pain  along  the  urethra  to  the  end  of 
the  penis.  Genital  symptoms  also  appear,  such  as  painful  emissions, 
hemospermia,  and  testicular  pain,  and  there  may  be  constant  pain 
in  the  rectum,  aggravated  by  defecation.  Hematuria  may  be  severe, 
and  usually  follows  renal  colic.  During  an  attack  of  colic  there  may 
be  oliguria  or  temporary  anuria,  and  under  certain  conditions  calculous 
anuria  becomes  established. 

Pus,  bacteria,  crystals,  and  tube  casts  may  be  present,  and  phos- 
phaturia  is  sometimes  observed. 

The  complications  that  may  occur  are  calculous  anuria,  infection 
(usually  hematogenous),  and  chronic  obstruction.  As  a  result  of 
infection,  pyelonephritis  or  pyonephrosis  may  develop,  and  as  a  result 
of  obstruction,  hydronephrosis. 

Examination  — There  may  be  tenderness  over  the  impacted 
calculus  ;  if  the  stone  is  at  the  lower  end  of  the  ureter  it  may  be  felt 
per  rectum  or  per  vaginam.  On  cystoscopy  the  ureteric  orifice  is 
unaltered,  or  shows  surrounding  congestion  and  thick  and  gaping  lips  ; 
sometimes  it  is  puckered  and  surrounded  by  heaped-up  velvety  mucous 
membrane  or  by  cedematous  bullae.  Occasionally  the  trigone  is  hidden 
with  cedematous  mucous  membrane.  A  stone  impacted  in  the  intra 
mural  portion  of  the  ureter  is  seen  as  a  red  swelling  outside  and  above 
the  ureteric  orifice  ;  its  brown  or  white  tip  may  project  from  the 
opening. 

The  efflux  may  be  rapid  and  forceful,  and  may  be  tinged  with 
blood  or  cloudy  with  pus.  If  a  stone  be  impacted  low  down,  the 
movements  of  the  orifice  are  often  slow,  and  the  efflux  is  discharged 
feebly. 

The  ureter  may  be  sounded  by  means  of  a  ureteral  catheter  or  a 
solid  bougie.  In  female  subjects  Kelly  has  used  wax-tipped  bougies 
which  show  scratches  on  the  wax  when  a  calculus  is  present. 

Radiography  is  the  most  reliable  method  of  diagnosis.  Stones  as 
small  as  a  split  pea,  or  even  smaller,  can  be  demonstrated.  Very  minute 
calculi  may  be  overlooked,  and  pure  uric-acid  calculi,  which  are  rare, 
do  not  throw  a  shadow.  The  diagnosis  of  small  stone  shadows  may 
be  confused  by  the  shadows  of  the  vertebral  transverse  processes, 
the  sacrum,  ischial  spine,  ami  the  horizontal  ramus  of  the  pubes,  or 
by  calcified  lymph-glands,  calcified  appendices  cpiploice,  opaque  bodies 
in  the  appendix,  atheromatous  arteries,  phleboliths,  calcareous  deposits 
in  old  scars  or  chronic  inflammatory  tissue  or  on  ligatures,  calcareous 
deposits  in  the  seminal  vesicles,  intestinal  contents  (Blaud's  pills, 
bismuth-covered  feces,  etc.),  or  enteroliths.     A  differential  diagnosis 


THE    BLADDER  845 

4<  Hindi'  by  the  position  <>f  the  shadow,  the  Bhape,  number,  and  clinical 
history.  In  doubtful  cases  Btereoscopic  radiograms  should  be  taken 
after  passing  an  opaque  bougie  up  the  ureter. 

1.  Diuretic  treatment.  If  small  stones  have  recently  passed 
into  the  ureter  with  recurring  attacks  of  renal  colic,  and  especially 
if  a  calculus  has  previously  been  passed,  diuretics  such  as  potassium 
citrate  and  acetate,  theocin  sodium  acetate  Contrexeville,  Evian, 
or  Vittel  water  should  be  administered,  together  with  antispasmodics 
such  as  atropine  or  belladonna. 

The  treatment  should  be  limited  to  four  or  six  months.  When 
dilatation  of  the  kidney  is  commencing  (as  shown  by  the  collargol 
pyelographic  method),  operation  should  be  undertaken  without  delay. 

2.  Instrumental  treatment. — The  passage  of  a  bougie  up 
the  ureter,  or  of  a  special  ureteric  catheter  with  a  distensible  balloon, 
and  the  injection  of  oil  and  eucaine  into  the  ureter,  h.ave  been  used  in 
special  cases. 

3.  Operative  treatment. — This  is  indicated — (1)  in  calculous 
anuria,  (2)  where  medicinal  treatment  has  failed,  (3)  where  infection 
has  occurred,  (4)  where  dilatation  of  the  kidney  is  commencing. 

A  calculus  situated  in  the  lumbar  segment  of  the  ureter  is  exposed 
by  an  oblique  lumbar  incision  ;  one  impacted  at  the  pelvic  brim  is 
reached  by  a  curved  incision  commencing  at  the  level  of  the  anterior 
superior  iliac  spine,  and  passing  downwTards  and  inwards  parallel  to 
Poupart's  ligament  and  about  2  in.  above  it.  The  peritoneum  is 
raised  and  the  ureter  is  found  adhering  to  it.  A  calculus  arrested  in 
the  pelvic  portion  of  the  ureter  may  be  removed  by  the  same  route, 
or  by  the  sacral  extraperitoneal  route  of  Morris.  The  latter  operation 
is  carried  out  by  an  incision  parallel  to  the  sacral  spines,  2  in.  from 
the  middle  line,  and  carried  down  beyond  the  coccyx.  The  gluteus 
maximus  muscle  and  the  sacro-sciatic  ligament  are  divided.  In  a 
third  method  the  abdomen  is  opened  in  the  middle  line  and  the  peri- 
toneum incised  over  the  ureter.  The  vaginal  route  is  used  when  the 
stone  can  be  felt  from  the  vagina.  A  calculus  in  the  intramural  portion 
of  the  ureter  is  removed  from  within  the  bladder  after  suprapubic  cysto- 
tomy.    In  all  cases  stricture  of  the  ureter  should  be  sought  and  treated. 

Results. — Excluding  cases  of  calculous  anuria,  extraperitoneal 
ureterolithotomy  has  an  operative  mortality  of  5"5  per  cent.  Eecur- 
rence  is  rare. 

THE  BLADDER 

Anatomy.— The  bladder  normally  holds  8  to  10  oz.  In  moderate 
distension  about  1 J  in.  of  the  anterior  wall  of  the  viscus  above  the  symphysis 
pubis  is  uncovered  by  peritoneum.  In  front  of  the  bladder,  behind  the 
pubic  symphysis,  is  the  space  of  Retzius,   filled  with  areolar  tissue.     The 


846  THE   BLADDER 

infernal  meatus  of  the  urethra  is  .111  a  level  with  the  middle  of  the  symphysis 
pubis  and  about  2  cm.  behind  it.  This  is  the  most  fixed  part  of  the  bladder. 
The  base  in  the  male  is  in  relation  to  the  prostate,  which  underlies  the  anterior 
half  of  the  trigone,  and  behind  this  lie  the  seminal  vesicles,  above  which 
is  the  peritoneum  of  the  recto-vesical  pouch. 

In  the  female  bladder  the  base  is  in  relation  to  the  anterior  vaginal  wall, 
in  which  it  is  adherent.  The  anterior  fornix  of  the  vagina  is  in  relation  to 
the  bladder  tor  about  1  in.  behind  the  base  of  the  trigone,  and  behind  this 
the  anterior  surface  of  the  uterus  lies  upon  the  posterior  wall  of  the  bladder 
almost  to  the  apex.  At  the  apex  of  the  bladder  the  peritoneum  covers  it  for 
a  short  distance  before  being  reflected  on  to  the  uterus.  In  the  child,  about 
one-half  of  the  bladder  lies  above  the  pubic  symphysis  (Symington).  The 
anterior  surface  is  entirely  uncovered,  and  the  posterior  completely  covered 
by  peritoneum. 

The  trigone  of  the  bladder  is  a  structure  distinct  from  the  rest  of  the 
organ,  and  the  muscular  fibres  are  derived  from  the  internal  longitudinal 
layer  of  the  ureters,  which  unite  to  form  the  interureteric  bar  of  Mercier, 
and  also  pass  forwards  to  the  internal  meatus,  interlacing  to  form  a  thick 
muscular  layer,  and  passing  into  the  internal  longitudinal  muscular  layer  of 
the  urethra. 

The  bladder  sphincter  consists  of  non-striped  muscle  fibres  continuous 
with  the  muscle  of  the  trigone  lying  on  the  upper  surface  of  the  prostate. 

The  mucous  membrane  is  composed  of  transitional  epithelium,  and  there 
are  no  papillae.  The  mucous  membrane  of  the  trigone  is  thick  and  adherent, 
that  over  the  rest  of  the  bladder  thinner  and  freely  movable. 

The  lymphatics  from  the  anterior  surface  pass  to  glands  along  the  external 
iliac  vessels,  those  of  the  upper  part  of  the  bladder  pass  to  the  external  iliac 
and  hypogastric  glands,  and  those  of  the  lower  part  and  posterior  wall  pass 
to  the  sacral  ganglia  at  the  bifurcation  of  the  aorta. 

The  nerve  supply  is  derived  from  the  2nd,  3rd,  and  4th  sacral  nerves. 
The  sympathetic  nerves  are  derived  from  the  hypogastric  and  hemorrhoidal 
plexuses.  The  lowest  reflex  centre  for  the  bladder  is  contained  in  these 
sympathetic  plexuses. 

Examination. — A  greatly  distended  bladder  forms  a  prominent 
rounded  suprapubic  swelling,  which  can  be  felt  as  a  smooth,  round,  elastic 
mass,  and  is  dull  on  percussion. 

On  rectal  examination  about  1J  in.  of  the  bladder  base  just  behind  the 
trigone  can  be  felt  above  the  prostate,  and  a  bimanual  examination  can 
be  made  with  the  other  hand  above  the  pubes.  A  distended  bladder  forms 
a  soft  cushion  which  tends  to  bury  the  prostate.  The  infiltration  of  a  malig- 
nant growth  at  the  base  of  the  bladder  may  be  detected  in  this  situation. 

On  vaginal  examination  the  short  urethra  can  be  felt  in  the  anterior 
vaginal  wall,  and  the  trigone  of  the  bladder  can  sometimes  be  defined. 
Behind  this  the  bladder  base  can  be  palpated  from  the  anterior  fornix. 

Examination  by  catheters  and  sounds.— The  passage  of 
a  catheter  is  required  to  withdraw  the  urine  in  vesical  atony  or  urethral 
obstruction,  to  ascertain  the  presence  and  quantity  of  residual  urine,  or  to 
obtain  an  uncontaminated  specimen  of  urine  from  the  bladder.  A  calculus 
is  sometimes  felt  on  passing  a  catheter,  and  a  portion  of  growth  may  be 
caught  in  the  eye  of  a  catheter. 

The  most  stringent  antiseptic  precautions  must  be  used  in  passing  instru- 
ments into  the  bladder.  The  method  of  passing  instruments  is  described  at 
p.  893. 


CYSTOSCOPY  847 

For  sounding  the  bladder  the  organ  should  contain  6  8  oz.  of  fluid.  The 
Btone  Bound  1--  introduced  in  the  same  way  as  a  metal  catheter,  and  when  the 
beak  engages  in  the  prostatic  urethra  tin-  handle  is  fullj  depressed  between 
the  thighs  and  then  |>us! km l  onwards  bo  thai  the  beak  rides  over  the  posterior 
lip  of  the  interna]  meatus.  The  bladder  Bhould  be  systematically  searched 
by  turning  the  handle  from  side  to  side  while  slowly  withdrawing. 

Exploration   by   operation.    When  necessary  the  bladder  may  be 
opened   Buprapubically  and   the   patient   placed   in  the  Trendelenburg 
ti.m.     Willi  bladder  retractors  and  the  help  of  a  head  lamp  the  interim-  of 
the  bladder  can  be  thoroughly  searched. 

The  perineal  route  in  the  male  and  the  urethral  and  vaginal  routes  in  the 
female  are  unsatisfactory  and  inadequate  methods  of  exploration. 

Radiography  is  discussed  elsewhere  (Vol.  I.,  p.  629). 

Cystoscopy.— There  are  two  methods  of  cystoscopy — (1)  indirect. 
(2)   direct. 

1.  Indirect  Cystoscopy. — This  is  carried  out  by  means  of  a  cystoscope  aftei 
distension  of  the  bladder  with  fluid.  The  various  forms  of  cystoscope  are 
described  in  special  works  on  the  subject.  For  routine  use  an  "  irrigation 
cystoscope  is  most  useful.  This  consists  of  a  hollow  tube  with  an  angled 
beak  which  carries  a  small  electric  lamp.  At  the  proximal  end  of  the  tube 
there  is  a  valve  which  prevents  the  escape  of  the  fluid  until  required.  A  tele- 
scope with  a  prism  and  lenses  fits  the  interior  of  the  tube  and  is  slipped  in 
after  the  bladder  is  washed  and  distended.  The  patient  lies  on  a  couch  with 
a  sand-pillow  beneath  the  pelvis,  or  sits  in  a  special  chair  with  the  knees  and 
hips  flexed  and  the  thighs  widely  apart.  The  urethra  is  anaesthetized  by 
instilling  15  minims  of  a  2  per  cent,  solution  of  cocaine  into  the  prostatic 
urethra  by  means  of  a  Guyon's  syringe.  The  catheter  portion  of  the  cystoscope 
is  lubricated  with  glycerine  and  introduced,  and  the  bladder  filled  with  warm 
boric  solution.  The  telescope  is  now  introduced,  the  light  switched  on,  and 
the  window  turned  to  the  base  of  the  bladder.  Careful  and  prolonged  washing 
may  be  necessary  to  obtain  a  clear  medium  when  hematuria  or  pyuria  is 
present,  and  a  weak  solution  of  silver  nitrate  (1  in  10,000)  or  a  small  quantity 
of  adrenalin  may  be  used  in  order  to  stop  oozing. 

2.  Direct  cystoscopy. — This  method  was  perfected  by  Kelly,  and  has  been 
modified  by  Luys  and  others.  Kelly's  specula  are  used  for  women  only, 
and  are  plated  metal  cylinders  3|  in.  long  with  a  funnel-shaped  expansion 
and  a  handle  at  the  outer  end.  The  instrument  is  introduced  with  an  obturator 
after  dilatation  of  the  urethra.  General  anaesthesia  may  be  necessary.  The 
patient  is  placed  in  the  knee-chest  position,  the  speculum  is  introduced 
and  the  obturator  withdrawn.  Air  rushes  in  and  distends  the  bladder. 
and  light  is  projected  through  the  tube  from  a  head-lamp.  Luys  has 
modified  this  method,  and  uses  it  in  the  male  also.  His  instrument  con- 
sists of  a  metal  tube  10  cm.  long  for  female,  and  18  cm.  for  male  subjects. 
The  patient  is  placed  in  the  Trendelenburg  position  with  local  or  general 
anaesthesia. 

The  direct  methods  are  inferior  to  the  indirect  where  examination  only 
is  desired.  There  is  frequently  difficulty  in  obtaining  the  proper  distension 
of  the  bladder  with  the  atmospheric  pressure,  and  the  position  of  the  patient 
is  irksome  and  embarrassing.  Urine  tends  to  collect  in  the  bladder  during 
the  examination,  and  must  be  removed  with  a  suction  apparatus.  Where 
applications  to  the  interior  of  the  bladder  are  necessary,  or  foreign  bodies 
have  to  be  removed,  the  direct  methods  are  invaluable. 

The  methods  of  collecting  urine  from    each   kidney  have  already  been 


848  THE   BLADDER 

considered  (p.  780).  The  tests  of  the  function  of  each  kidney  should  be 
used.  The  most  suitable  are  the  phloridzin  and  the  phenol-sulphone- 
phthalein  tests  (p.  779). 

INCONTINENCE   OF   URINE 

Incontinence  of  urine  may  be  false  or  true. 

In  false  incontinence  the  bladder  is  full,  as  in  chronic  retention 
from  prostatic  or  urethral  obstruction,  and  the  escape  is  the  over- 
flow from  the  distended  organ. 

In  true  incontinence  the  bladder  is  not  distended.  Of  this  there 
are  two  types,  passive  and  active.  In  the  passive  type  the  sphincter 
is  paralysed  and  the  urine  dribbles  away  without  distending  the 
bladder  and  without  the  assistance  of  contraction  of  the  bladder.  In 
the  active  type  the  urine  is  expelled  by  contraction  of  the  bladder. 
Here  there  is  sphincter  action,  but  it  is  either  too  weak  to  resist 
normal  contractions  of  the  bladder,  or  the  contractions  are  so  strong 
as  to  overcome  a  normal  sphincter. 

Incontinence  due  to  Mechanical  Causes 

This  occurs  more  frequently  in  women  than  in  men.  It  may  be 
observed  in  a  very  slight  degree  on  exertion  in  otherwise  normal 
individuals.  Parturition  is  a  frequent  cause.  In  older  women  in- 
continence occurs  in  combination  with  cystocele.  Forcible  dilata- 
tion of  the  urethra  for  digital  examination  of  the  bladder  was  at  one 
time  a  frequent  cause  of  incontinence  in  women.  In  men,  perineal 
prostatectomy  or  the  perineal  drainage  of  the  prostatic  cavity  after 
suprapubic  prostatectomy  may  cause  incontinence. 

Treatment. — In  slight  cases  strychnine  and  ergot  should  be 
given.  The  use  of  a  vaginal  pessary  is  of  service.  A  cystocele  should 
be  excised. 

For  urethral  dilatation  Duret  has  transplanted  the  urethra  for- 
wards to  the  neighbourhood  of  the  clitoris,  and  Gersuny  operates  by 
dissecting  up  the  female  urethra  and  twisting  it  on  its  long  axis. 
Paraffin  has  been  injected  around  the  urethra  and  vesical  orifice  in 
incontinence  of  urine  in  the  female.  If  treatment  fails  a  urinal  must 
be  worn. 

Incontinence  due  to  Nervous  Disease 

Incontinence  occurs  in  organic  diseases  of  the  spinal  cord.  In 
some  cases  there  is  false  incontinence  (i.e.  chronic  distension  and 
overflow),  especially  in  the  early  stages  of  the  bladder  affections  of 
tabes  and  transverse  lesions  of  the  cord.  After  a  time  the  bladder 
regains  some  of  its  contractile  power,  the  residual  urine  is  reduced  to 
8  or  10  oz.,  and  the  patient  can  expel  the  rest  voluntarily.  Incon- 
tinence in  these  cases  is  first   noticed  at   night ;   bed-wetting  which 


INCONTINENCE  i- 

develops  in  adult  life  withoul  other  symptoms  should  lead  to  a  careful 
examination  of  the  central  nervous  system. 

In  multiple  Bclerosis  a  differenl  type  of  incontinence  is  met  with, 
the  bladder  being  contracted  and  urine  spasmodically  ejected  without 
control. 

Treatment. — The  over  -  distended  bladder  should  be  slowly 
emptied  by  the  catheter  al  regular  intervals  under  t  be  si  rictesl  aseptic 
precautions.  If  there  is  complete  retention  this  should  be  done  three 
times  in  twenty-four  hours.  The  bladder  should  !>«■  washed  with 
silver-nitrate  solution  (1  in  10,000)  if  any  sign  of  infection  is  observi  d. 
Urinary  antiseptics  (urotropine3  etc.)  are  combined  with  strychnine 
and  ergot,  and  the  bowels  carefully  regulated.  For  continual  incon- 
tinence a  urinal  must  be  worn. 

Incontinence  due  to  Bladder  Spasm 
In  multiple  sclerosis,  incontinence  is  due  to  spasm.     In  acute  in- 
flammation of  the  bladder  and  prostatic  urethra,  uncontrollable  spasm 
may  cause  active  incontinence.      This  is  usually  nocturnal.      Tuber- 
culosis of  the  bladder  is  a  frequent  cause. 

Treatment. — In  acute  cases  hot  fomentations  should  be  applied 
suprapubically  and  on  the  perineum,  morphia  and  belladonna  sup- 
positories used,  and  a  hot -water  enema,  to  which  30  gr.  of  antipyrin 
have  been  added,  given. 

Contrexeville  or  Yittel  water  and  sandalwood  oil  may  be  adminis- 
tered, and  hot  sitz-baths  are  useful.  In  chronic  cases  diuretics  and 
sandalwood,  belladonna  and  hyoscyamus,  and  small  doses  of  opium 
should  be  given,  and  the  cystitis  simultaneously  treated.  In  tuber- 
culous cystitis  the  bladder  should  not  be  washed. 

Incontinence  of  Childhood — Nocturnal  Enuresis — Essential 

Enuresis 

Up  to  the  end  of  the  first  year  the  bladder  acts  automatically. 
About  that  time  mental  control  by  inhibition  of  the  act  of  micturi- 
tion begins,  and  by  the  end  of  eighteen  months,  or  at  most  two  years, 
it  is  fairly  established,  although  there  may  still  be  occasional  lapses 
up  to  the  age  of  3  years.  After  that  age  constant  or  frequent  bed- 
wetting  must  be  regarded  as  abnormal.  The  onset  of  enuresis  is 
usually  observed  between  the  ages  of  5  and  8,  but  the  nocturnal 
control  may  never  have  been  estabhshed.  Enuresis  is  usually  noc- 
turnal, sometimes  it  is  also  diurnal,  rarely  it  is  diurnal  only.  Boys 
and  girls  are  equally  affected. 

Etiology. — In  certain  cases  some  source  of  irritation  is  present, 
such  as  thread-worms,  anal  fissure,  vulvitis,  phimosis,  and  balanitis, 
and  the  incontinence  is  looked  upon  as  reflex.  Enlarged  tonsils  and 
3  c 


S5o  THE   BLADDER 

adenoids  are  present  in   some   eases,  and   enuresis  is  said  to  be  due 
to  partial  asphyxia  during  sleep. 

In  other  cases  there  is  some  abnormality  in  the  urine  or  bladder, 
such  as  highly  acid  urine,  uric-acid  crystals,  phosphaturia .  bacilluria, 
cystitis,  vesical  calculus,  or  tuberculous  cystitis.  In  some  cases  no 
source  of  irritation,  no  alteration  in  the  urine  or  disease  of  the  bladder 
can  be  found.  These  cases  are  called  "  essential  enuresis/'  In  these 
children  there  is  frequently  an  heredity  of  nervous  disease,  such  as 
epilepsy,  neurasthenia,  alcoholism,  insanity,  etc.  The  child  may  be 
nervous,  quiet,  sensitive,  and  furtive,  and  often  suffers  from  stutter- 
ing and  habit  spasms.  The  enuresis  is  always  worse  after  excite- 
ment. In  a  small  number  of  cases  the  enuresis  occurs  during  a  minor 
epileptic  attack. 

Prognosis. — Where  some  abnormality  amenable  to  treatment 
is  found,  the  prognosis  is  good.  In  the  majority  of  cases  of  essential 
enuresis  continence  becomes  complete  with  or  before  the  advent  of 
puberty.  Most  cases  get  well  under  treatment,  but  in  a  small  per- 
centage the  enuresis  persists,  sometimes  into  adult  life. 

Treatment — All  sources  of  irritation,  such  as  thread-worms, 
phimosis,  or  anal  fissure,  hyperacid  urine,  phosphaturia,  bacilluria, 
cystitis,   stone,   etc.,  should  receive  appropriate  treatment. 

When  no  source  of  irritation  is  found,  treatment  along  the  fol- 
lowing lines  is  indicated  :  Mental  excitement  and  late  hours  should 
be  avoided,  and  sometimes  even  school  and  lessons  temporarily  stopped. 
The  principal  meal  should  be  at  mid-day,  and  fluids  prohibited  after 
five  o'clock.  Tea,  coffee,  ginger-beer  and  ginger-ale,  highly  seasoned 
foods,  sugar,  and  pastry  should  be  avoided,  and  meat  taken  only  in 
moderation.  The  child  is  trained  to  hold  water  as  long  as  possible 
during  the  day,  and  to  empty  the  bladder  before  bedtime.  He  should 
be  wakened  to  micturate  after  about  one  and  a  half  hour's  sleep. 
Belladonna  is  given  in  doses  suitable  to  the  patient's  age  and  idiosyn- 
crasy. In  a  child  of  five  years  or  over  the  dose  should  commence 
with  3  minims  of  the  tincture,  and  slowly  increase  up  to  30  or  40 
minims  three  times  a  day  unless  symptoms  of  poisoning  appear.  If 
the  enuresis  is  controlled  the  dose  is  kept  a  little  beyond  the  point 
of  control  for  a  fortnight,  and  then  gradually  reduced.  Tincture  of 
lycopodium  may  be  combined  with  belladonna.  Nux  vomica  and 
ergot  in  small  doses  are  sometimes  useful,  and  potassium  bromide,  anti- 
pyrin,  and  fluid  extract  of  Rhus  aromatica  have  been  recommended. 

Local  treatment  should,  if  possible,  be  avoided  ;  but  it  is  success- 
ful in  some  cases  where  other  methods  have  failed.  This  consists  in 
the  instillation  into  the  prostatic  urethra  of  nitrate  of  silver  (1  per 
cent.),  and  treatment  with  the  continuous  current  applied  by  means 
of  a  urethral  electrode. 


RETENTION   OF    URINE  ' 

Cathelin  has  suggested  the  injection  of  fluid  into  the  saciaJ  canal 
with  the  objed  of  causing  pressure  <>n  the  sacral  uerves.  He  claims 
80  per  cent,  of  cures,  bu1  the  treatmeni  has  not  been  so  successful  in 

other  hands. 

RETENTION    OP   URINE 
Etiology.    The  causes  of  retention  of    urine    may  be  classified 

as  follows : — 

1.  Retention  with  obstruction,  (a)  Prostate. — (1)  Simple  en- 
largement, (2)  malignanl  disease,  (3)  stone,  (4)  acute  prostatitis  and 
prostatic  abscess.  (/>)  Urethra. — (1)  Rupture,  of  urethra,  (2)  acute 
urethritis,  (3)  stricture,  (4)  stone  and  foreign  bodies,  (5)  pressure  from 
without,  pelvic  tumours,  etc. 

2.  Retention  due  to  atony. — (a)  With  symptoms  of  nervous 
disease  ;  tabes  and  other  spinal  lesions,  (b)  Without  symptoms  of 
nervous  disease  ;   idiopathic  atony. 

3.  Retention  in  acute  and  chronic  intoxications. — Typhoid, 
appendicitis,  salpingitis,  arsenical,  mercurial,  belladonna,  or  lead 
poisoning,  and  syphilis. 

4.  Retention  from  inhibition  or  spasm. — Hysterical  reten- 
tion ;  retention  after  anal  and  rectal  operations. 

Diagnosis. — It  is  necessary  to  distinguish  between  anuria  and 
retention  and  between  atonic  and  obstructive  retention.  In  obstructive 
retention  the  form  of  obstruction  must  be  ascertained. 

In  anuria  there  have  been  previous  signs  of  renal  disease,  but  no 
symptoms  of  disease  of  the  bladder  or  urethra.  There  is  no  pain, 
no  distension  of  the  bladder,  and  an  instrument  passes  easily  into 
the  bladder  but  draws  no  urine.  In  retention  of  urine  there  is 
usually  a  history  of  increasing  difficulty  of  micturition  and  other 
signs  of  obstruction.  Symptoms  of  renal  disease  are  absent  or 
insignificant.    The  bladder  is  distended. 

In  retention  due  to  atony  there  is  no  pain  and  no  desire  to  mictu- 
rate. In  obstructive  retention  there  are  recurrent  spasmodic  attempts 
to  empty  the  bladder ;  these  are  sometimes  absent  in  old  men. 

A  large-sized  instrument  enters  the  bladder  easily  if  retention  is 
due  to  atony,  but  is  arrested  if  retention  is  due  to  obstruction  ;  the 
presence  of  signs  of  spinal  disease  clinches  the  diagnosis. 

In  young  men  the  most  frequent  cause  of  acute  retention  is  gonor- 
rhoea, and  there  is  a  history  of  an  acute  discharge.  In  adult  life  reten- 
tion is  usually  due  to  stricture,  and  there  is  a  history  of  gradually 
increasing  difficulty  of  micturition,  culminating  in  complete  retention 
after  alcoholic  excess  or  exposure  to  cold.  The  passage  of  an  instru- 
ment confirms  the  diagnosis. 

In  old  men  enlargement  of  the  prostate  is  the  most  frequent  cause 
of  retention.     There  is  a  history  of  nocturnal  frequency  and  increas- 


852  THE    BLADDER 

ing   difficulty,   and   rectal   examination   shows   that   the   prostate   is 
enlarged. 

Treatment. — The  following  is  the  treatment  suitable  to  the 
chief  types  : — 

1.  Acute  inflammation  of  the  urethra  {gonorrhoea,  etc.). — Every  means 
should  be  tried  to  relieve  the  retention  without  the  passage  of  a  catheter. 
A  hot  bath  or  sitz-bath,  followed  by  a  rectal  injection  of  hot  water 
and  a  suppository  containing  belladonna  and  opium,  should  be  given. 
If  relief  is  not  obtained  in  half  to  three-quarters  of  an  hour  an  anaes- 
thetic should  be  given,  the  urethra  thoroughly  washed  out  with 
potassium  permanganate  (1  in  5,000),  and  then  a  rubber  catheter 
passed.  The  bladder  should  be  washed  with  permanganate  or  prot- 
argol  (1  in  10,000)  solution  and  a  little  of  the  solution  left  in  the 
bladder.  If  acute  prostatitis  and  prostatic  abscess  is  present  early 
operation  is  indicated. 

2.  Obstruction  of  the  urethra  by  stone,  foreign  bodies,  pedunculated 
bladder  growths,  blood  clot,  etc. — Relief  by  catheter  should  be  given 
without  delay.  Spasm  of  the  compressor  muscle  may  hinder  the 
passage  of  the  catheter  and  may  necessitate  the  use  of  several  metal 
sounds  before  the  catheter  can  be  introduced; 

If  the  bladder  is  distended  with  blood  clot  an  attempt  may  be 
made  with  a  large  metal  catheter  to  break  up  the  clot  and  wash  it 
out,  or  a  lithotrite  may  be  used  and  an  evacuating  cannula.  Should 
these  methods  fail,  the  bladder  must  be  opened  suprapubically,  the 
masses  of  clot  removed,  and  a  large  rubber  drain  inserted. 

3.  The  distended  atonic  bladder  of  spinal  disease  should  be  regu- 
larly eatheterized  with  the  same  precautions  as  in  enlarged  prostate. 

4.  Retention  from  reflex  spasm  after  operations,  and  retention  due  to 
hysteria. — In  operation  cases  the  catheter  is  passed  without  delay. 
In  other  cases  hot  baths  and  other  means  of  relieving  spasm  {see  Acute 
Inflammation)  should  first  be  tried.  A  metal  catheter  is  the  best 
instrument  for  these  cases. 

5.  Retention  with  enlarged  prostate. — The  preliminary  measures 
detailed  above  may  be  tried,  but  recourse  to  the  catheter  will  nearly 
always  be  necessary.  The  following  points  are  of  the  utmost  import- 
ance : — 

i.  The  most  rigid  asepsis  must  be  practised, 
ii.  The  delicate  handling  of  instruments  is  essential, 
iii.  All  the  urine   of  an  over-distended  bladder  must  not  be 
withdrawn  at  once,  or  must  be  drawn  off  very  slowly. 
Coude  and  bicoude  catheters  are  most  suitable.     When  obstruc- 
tion is  felt  the  greatest  gentleness  is  exercised  ;   scmetimes  twisting  to 
one  side  or  another,  or  withdrawing  a  little  and  pushing  on,  will  be 
successful.     In    cases    of    enlarged    prostate    the    urethra    is    greatly 


RETENTION   OF    URINE:    TREATMENT  833 

elongated,  and  may  require  deep  insert  inn  of  a  metal  prostatic  catheter 
with  a  large  curve  and  a  long  beak  ;  a  gum-elastic  catheter  benl  int<» 
a  full  curve  or  into  some  other  shape  may  be  successful  when  other 
«at Deters  have  Eailed. 

These  methods  tailing,  suprapubic  puncture  will  be  necessary  [see 
below). 

The  vesical  or  renal  hemorrhage,  or  the  suppression  thai  may 
follow  sudden  emptying  of  an  over-distended  bladder,  are  avoided  by 
keeping  the  patient  warm  in  bed,  and  by  drawing  off  only  LO  or  15 
oz.  at  intervals  of  half  an  hour  until  the  bladder  is  empty.  Another 
method  is  to  tie  in  a  catheter  of  very  fine  calibre  and  allow  the  urine 
to  dribble  slowly  away.  When  the  bladder  is  empty  a  few  syringe- 
fuls  of  silver  nitrate  solution  (1  in  10,000)  should  be  injected  and 
allowed  to  escape,  and  the  catheter  tied  in.  Stimulants  and  a  mixture 
containing  nrotropine,  strychnine,  citrate  of  potash,  and  infusion  of 
buchu  should  be  given. 

After  several  days  of  continuous  bladder  drainage  the  decision 
will  have  to  be  made  as  to  whether  "  catheter  life  "  is  to  be  com- 
menced or  an  operation  performed. 

6.  Retention  with  stricture. — A  hot  sitz-bath  and  rectal  injections, 
followed  by  a  suppository  of  morphia  (£  gr.),  should  be  tried.  This  fail- 
ing, a  catheter  should  be  passed,  preceded  by  a  No.  7  or  8  French 
bougie  if  necessary.  When  a  filiform  bougie  only  will  pass,  it  should 
be  tied  in  place.  After  half  an  hour  the  urine  begins  to  trickle  along- 
side the  bougie  ;  a  few  hours  later  a  larger  instrument,  and  eventu- 
ally a  catheter,  can  be  introduced. 

A  more  rapid  method  is  to  use  a  metal  catheter  with  a  conical 
end  which  screws  on  to  a  filiform  bougie.  The  bougie  acts  as  a 
guide,  and  the  catheter  is  forced  through  the  stricture.  Harrison  s 
whip  bougies  are  useful,  especially  if  laterally  grooved  to  facilitate 
escape  of  urine.  There  is  less  danger  of  completely  emptying  a 
distended  bladder  in  a  case  of  stricture  than  in  enlarged  prostate. 

If  instruments  fail,  the  bladder  must  be  emptied  by  suprapubic 
puncture  an  inch  above  the  upper  margin  of  the  pubic  symphysis  in 
the  middle  line.  The  skin  is  incised,  and  then  the  aspirating  needle 
introduced.  There  is  little  risk  of  injuring  the  peritoneum  when  the 
bladder  is  distended  and  the  percussion  note  dull.  The  aspirating 
needle  should  not  be  large,  lest  leakage  at  the  point  of  puncture  of 
the  bladder  take  place.  There  is  a  danger  of  prevesical  abscess  if  the 
urine  is  septic.  Usually  after  a  single  aspiration  an  instrument  on 
be  introduced  through  the  stricture  and  tied  in,  but  in  rare  instances 
the  puncture  must  be  repeated. 

Operation  for  the  relief  of  the  stricture  should  be  performed  as 
soon  as  possible. 


854  THE    BLADDER 

EXTROVERSION 

In  this  rare  condition  the  anterior  vesical  wall  is  congenitally  absent,  so 
that  the  mucous  membrane  is  exposed  and  the  urine  discharged  on  the 
surface.      Male   infants   are  more  frequently   affected   than  female. 

At  birth  there  is  a  dark-red,  plum-sized  suprapubic  swelling.  The  mucous 
membrane  becomes  folded,  irregular,  and  excoriated  ;  at  its  margin  there 
is  a  zone  of  scar  tissue  with  irregular  epithelial  ingrowths  into  the  mucosa. 
The  umbilicus  may  be  normal  and  separated  from  the  open  bladder  by 
healthy  skin,  or  the  bladder  may  fill  the  entire  space  from  the  umbilicus 
to  the  root  of  the  penis.  The  ureters,  which  are  frequently  dilated,  open 
on  two  nipples  close  together,  and  the  trigone  is  undeveloped.  The  penis 
is  undeveloped  and  epispadiac  ;  at  its  base  in  a  small  pocket  are  the  sinus 
pocularis  and  ejaculatory  ducts.  The  foreskin  is  well  developed  in  the  form 
of  an  apron.  The  scrotum  is  split  or  rudimentary,  and  rarely  contains  the 
testicles.  The  prostate  is  absent  or  rudimentary.  The  pubic  bones  do  not 
unite  in  the  middle  line,  and  may  be  separated  by  3  in.  or  more.  Associated 
deformities,  such  as  hare-lip,  cleft  palate,  and  spina  bifida,  are  sometimes 
observed.  The  perineal  muscles  may  be  defective,  and  the  anal  sphincter 
ill  developed.  Less  extensive  degrees  of  this  maldevelopment  may  be 
observed.  The  condition  is  ascribed  either  to  an  arrest  of  development  or 
to  an  intra-uterine  rupture  of  the  bladder  following  obstruction. 

Symptoms  and  prognosis.— The  conditions  of  existence  are 
extremely  miserable.  There  is  constant  escape  of  urine,  saturating  the  clothes 
and  leading  to  inflammation  and  excoriation  of  the  skin.  The  mortality  from 
ascending  pyelonephritis  is  very  high,  but  occasionally  the  patients  attain 
adult  life  and  even  old  age. 

Treatment. — Of  the  many  operations  suggested,  the  following  are 
the  chief  types:— 

I.  Formation  of  a  reservoir  in  the  body. 

A.  From  the  bladder. 

i.  Closure  of  the  defect  by  osteoplastic  operation  (Trendelenburg), 
ii.  Closure  of  the  defect  by  flaps. 

(a)  Autoplastic  methods,  of  skin  (Woods)  or  of  intestine. 
{b)  Heteroplastic  methods. 

B.  From  the  rectum. 

i.  By  transplantation  of  the  ureters. 
ii.  By  vesico-rectal  fistula. 

C.  From  the  sigmoid  flexure. 

D.  From  the  vagina. 

II.  No  reservoir  formed   in  the  body. 

i.  Implantation  of  ureters  (a)  in  the  urethra  (Sonnenberg),  {b)  in  the 

skin, 
ii.  Nephrostomy. 
The  operation  that  has  given  the  most  successful  results  is  transplanta- 
tion of  ureters  and  trigone  into  the  sigmoid  flexure  by  Maydl's  method.  The 
danger  of  ascending  pyelonephritis  is  much  reduced  by  retaining  the  sphincter 
action  of  the  bladder  base.  Peritonitis  and  fistula  are  also  dangers.  The 
immediate  mortality  of  this  operation  varies  from  5-5  to  26*7  per  cent. 
Soubottine's  operation  consists  in  making  a  fistula  between  the  bladder  and 
the  rectum.  By  a  horse-shoe  incision  surrounding  the  rectal  aspect  of  the 
fistula  an  area  of  rectum  is  marked  out.  and  this  is  folded  so  as  to  form  a 
small  bladder,  the  lower  open  end  of  which  is  controlled  by  the  anal  sphincter. 
The  suprapubic  gap  in  the  anterior  bladder  wall  is  then  closed. 


VESICAL    DIVERTICULA 


855 


DIVERTICULA 

A  diverticulum  is  arpouoh  lined  with  vesioal  muoous  membrane,  Burronnded 

by  fibrous  tissue,  coarse  tat.  and  often  sume  non-striped  iniiseie.  and  00m ■ 
munioating  with  the  bladder  by  a  narrow  opening.  Diverticula  should  be 
distinguished  from  the  pouohes  or  saccules  of  a  sacculated  bladder  commonly 
seen  in  prostatic  obstruction.  They  are  single  <>r  multiple,  small  as  a  pea, 
or  as  large  as  or  larger  than  the  bladder  cavity.  Small  diverticula  are 
frequently  multiple.  The  orifice  has  sharply  defined  edges,  may  admit  a 
oroVi  quill  or  the  point  of  the  foretiniier,  and  frequently  is  surrounded  by 
trabeoulation.  The  ureteric  orifice  sometimes  opens  in  the  wall  ol  the 
diverticulum  or  close  to  its  orifice.     (Kg.  ~>47.) 

Diverticula    are   most   frequently   found   in   the   lateral   walls  or  on   the 
posterior   wall.       Rarely    they    open    on    the   trigone.      They   may  occur  in 
infants,    but     are   most    fre- 
quently found  in  male  adult 
life. 

Symptom  s.— T  h  e 
symptoms  are  usually  puz- 
zling and  irregular.  There 
may  be  apparently  causeless 
attacks  of  frequent  micturi- 
tion at  varying  intervals  or 
almost  continuously,  or  re- 
current attacks  of  difficulty 
and  retention  of  urine. 

Symptoms  are  sometimes 
entirely  absent,  and  the 
diverticulum  is  discovered 
accidentally.  Micturition  in 
two  parts  may  be  present 
in  large  diverticula.  Some- 
times the  second  supply  is 
purulent  when  the  first  is 
clear.  On  passing  a  cathe- 
ter the  bladder  is  apparently 
emptied,  when  the  point  of 
the  catheter  slips  onwards  and  a  large  quantity  of  urine  is  passed.  The 
edge  of  the  diverticulum  may  sometimes  be  felt  with  a  sound.  A  large 
diverticulum  can  be  felt  as  a  tumour  in  the  lower  part  of  the  abdomen  when 
the  bladder  is  distended.  Diagnosis  is  made  with  the  cystoscopy  The  dimen- 
sions and  position  of  a  diverticulum  are  demonstrated  by  skiagraphy  after 
distending  the  bladder  with  a  bismuth  emulsion. 

Complications — These  are— (1)  dilatation  of  one  or  both  kidneys, 
(2)  infection.  (3)  calculus  in  the  diverticulum,  (4)  malignant  growth  at  or 
near  the  opening. 

Prognosis  and  treatment.— The  prognosis  is  grave  when 
infection  has  taken  place  or  when  malignant  growth  exists.  After  infection, 
washing  the  bladder  has  little  effect  on  the  diverticulum.  In  the  female 
subject  a  Kelly's  tube  may  be  passed,  and  a  catheter  introduced  through 
this  into  the  orifice,  and  the  diverticulum  washed  out.  The  following  opera- 
tions have   been  performed  : — 

1.  Drainage  outside  the  bladder.— This  is  only  applicable  to  large  diver- 
ticula,  and   leads  to  a  permanent   urinary   fistula. 


Fig.  547. — Diverticulum  of  bladder 
(cystoscopic  view). 


856  THE    BLADDER 

2.  Closure  of  the  orifice  of  the  diverticulum  from  within  the  bladder, 
and  drainage  of  the  diverticulum  outside  the  bladder. 

3.  Drainage  into  the  bladder. — The  walls  of  the  bladder  and  diverti- 
culum are  split  upwards  or  downwards,  and  the  edges  stitched  together, 
so  that  the  cavity  of  the  diverticulum  is  thrown  into  the  bladder. 

4.  Excision  of  the  sac  and  repair  of  the  bladder  wall. — This  operation 
is  the  most  radical,  and  gives  good  results.  Where  the  diverticulum  lies  low 
in  the  pelvis  and  is  extensive  the  excision  is  very  difficult  and  may  be 
impossible. 

HERNIA 

This  is  rare,  occurring  in  only  1  per  cent,  of  hernia  operations.  It  is 
more  frequent  in  men,  and  in  advanced  life.  The  great  majority  of  bladder 
hernias  are  inguinal;  femoral  are  less  common;  and  the  obturator,  sciatic, 
and  perineal  varieties  are  very  infrequent. 

Etiology. — The  bladder  is  thin-walled  and  distended,  and  the 
abdominal  wall  weak.  Urethral  obstruction,  old  age,  coughing,  st  raining, 
traction  of  an  extraperitoneal  lipoma,  traction  on  the  peritoneum -covered 
area  of  the  bladder  by  a  large  hernia,  adhesions  between  the  bladder  and 
the  omentum  and  intestine,  are  recognized  causes. 

Pathological  anatomy. — There  are  three  varieties:  (I)  Extra- 
peritoneal :  The  bladder  is  prolapsed  without  a  hernial  sac  of  peritoneum. 
(2)  Intraperitoneal :  The  peritoneum-covered  portion  of  the  bladder  is  drawn 
into  a  hernial  sac  with  bowel  or  omentum.  (3)  Paraperitoneal  :  A  sac 
of  peritoneum  is  present,  and  adherent  to  this  is  the  bladder.  The  large 
majority  are  of  this  nature. 

The  communication  between  the  prolapsed  portion  and  the  bladder  is 
temporarily  narrowed,  but  there  is  no  permanent  constriction.  Cystitis  may 
be  present,  and  a  phosphatic  stone  has  been  known  to  form  in  the  prolapsed 
portion. 

Symptoms.— A  swelling  is  present  at  one  of  the  sites  of  hernia,  and 
has  the  following  characteristics:  (1)  It  is  irreducible.  (2)  It  is  large  when 
the  bladder  is  distended,  and  small  when  it  is  emptied.  (3)  Pressure  on  the 
swelling  causes  a  desire  to  micturate.  (4)  Fluctuation  may  be  detected. 
(5)  The  swelling  is  dull  on  percussion. 

Micturition  in  two  parts  is  a  common  symptom.  There  is  difficulty  in 
micturition,  and  sometimes  complete  retention,  and  the  patient  may  only 
be  able  to  pass  water  by  pressing  on  the  swelling,  or  in  a  certain  posture. 
If  a  catheter  is  introduced  it  may  pass  into  the  hernia  and  be  felt  under 
the  skin.     Strangulation  of  a  bladder  hernia  has  occurred  in  several  cases. 

Diagnosis. — In  67  per  cent,  of  cases  diagnosis  is  made  at  hernia 
operations.  Injury  of  the  bladder  seldom  occurs  if  the  neck  of  the  sac 
is  carefully  inspected  during  the  radical  cure  of  hernia. 

Treatment. — The  bladder  should  be  stripped  from  the  hernial  sac 
(paraperitoneal  variety),  or  reduced  with  the  other  hernial  contents  (intra- 
peritoneal variety).  If  the  bladder  is  opened  during  an  operation  it  should 
be  carefully  dissected  off  the  sac,  closed,  and  returned  to  the  pelvis,  and  a 
catheter  tied  in  the  urethra.  The  hernia  operation  is  concluded  in  the  usual 
manner. 

INVERSION  AND  PROLAPSE  (URETHRAL  CYSTOCELE) 

This  condition  occurs  in  women  and  female  children.  The  whole  thick- 
ness of  the  bladder  wall,  including  the  peritoneal  investment,  is  inverted 


RUPTURE   OF   THE    BLADDER  857 

through  the  urethra,  or  the  mucous  membrane  alone  is  prolapsed.  The 
exciting  cause  is  straining  due  to  coughing,  sneezing,  constipation,  or  diarrhoea. 
There  is  a  round  swelling  a1  the  meatus,  the  Bize  of  a  walnut  or  an  orange, 
covered  with  reddened,  easily  bleeding,  mucous  membrane,  on  which  the 

ureters    are   sometimes    visible.      The    tumour    is    tender,    inctf  iZ6   OD 

straining,  and  is  irreducible  or  onlj  reduoed  with  difficulty.  A  probe  passes 
along  the  urethra  alongside  the  tumour,  and  can  be  Bwepl  round  it.  i.ut 
is  not  free  in  the  bladder.    There  is  incontinence  of  urine    The  tumour  may 

not  reOUr   after    reduction.       .Melted    paraffin    has    been    injected    around    the 

lax  urethra.  Cysto-ureteropexy  and  plastic  operations  on  the  urethra  have 
been  successful. 

PERIVESICAL    HYDATID    CYSTS 

Hydatid  cysts  in  the  pelvic  subperitoneal  tissue  may  be  primarj  or,  more 
frequently,  secondary.  The  cyst  becomes  adherent  to  the  bladder,  prostate, 
and  rectum,  and  mounts  above  the  brim  of  the  pelvis.  There  is  bladder 
irritation,  pain  on  micturition,  and  later  retention  of  urine.  Sciatica  may  be 
present.  A  firm,  rounded,  dull  swelling  appears  above  the  pubes  and 
closely  reseml iles  the  distended  bladder.  On  passing  a  catheter  the  swelling 
remains,  and  on  bimanual  examination  fluctuation  can  be  detected.  Hydatid 
fremitus  is  rarely  elicited.  The  diagnosis  is  greatly  assisted  by  the  "  comple- 
ment-fixation "  reaction.  The  cyst  is  opened  suprapubically,  and  the  contents 
completely  removed.     The  cavity  is  drained  if  septic,  and  closed  if  aseptic. 

INJURIES 

Rupture 

This  may  involve  the  inner  coat  alone,  but  generally  it  is  com- 
plete. Fully  90  per  cent,  of  cases  occur  in  male  subjects,  and  usually 
between  the  ages  of  20  and  40.  The  bladder  is  invariably  distended 
at  the  time  of  the  rupture.  A  considerable  proportion  of  ruptures 
occur  during  alcoholic  intoxication,  and  follow  kicks,  blows,  or  crushes. 
In  fracture  of  the  pelvis  a  splinter  of  bone  may  penetrate  the  bladder. 
Rupture  may  also  result  from  indirect  violence,  such  as  falls  from  a 
height,  muscular  effort  or  straining,  and  it  has  followed  the  forcible 
injection  of  fluid  into  a  diseased  bladder.  Spontaneous  rupture  has 
occurred  in  an  ulcerated  or  cancerous  bladder. 

Pathology. — The  rent  is  most  frequently  situated  on  the 
postero-superior  Avail,  and  opens  the  peritoneal  cavity.  Extraperi- 
toneal rupture  is  less  common,  and  affects  the  anterior  or  lateral  walls. 
Rupture  of  the  base  or  lateral  walls  usually  results  from  fracture  of 
the  pelvis,  but  has  been  observed  without  fracture.  The  rupture  is 
single  and  usually  small  in  size,  with  clear-cut  or  bruised  margins. 
When  the  rupture  is  intraperitoneal  the  urine  escapes  into  the  peri- 
toneal cavity  and  general  peritonitis  Bupervenes.  Aseptic  urine  does 
not  necessarily  cause  peritonitis,  although  it  is  toxic  when  absorbed. 
The  urine  very  readily  becomes  infected,  usually  from  the  pi 
of  instruments.  In  extraperitoneal  rupture  the  urine  infiltrates  the 
cellular  planes  and  suppuration  follows. 


S5S  THE    BLADDER 

Clinical  features.— Shock  is  present  and  may  be  severe, 
but  occasionally  it  is  absent  and  symptoms  are  delayed. 

There  are  pain,  urgent  desire  to  micturate,  and  straining,  but  inability 
to  pass  water.  The  abdomen  is  rigid  and  tender,  there  is  no  dullness 
corresponding  to  a  distended  bladder,  and  the  patient  has  not  passed 
water  for  several  hours.  On  passing  a  catheter  a  little  blocdy  urine 
is  withdrawn.  Barely,  the  catheter  passes  through  the  rent,  and  a 
large  quantity  of  mine  i>  obtained.  If  a  catheter  is  passed  several 
times  the  quantity  of  urine  is  always  the  same  ;  and  if  the  patient  is 
set  upright  after  withdrawal  of  the  urine  a  large  quantity  can  be 
obtained,  although  immediately  before  this  the  bladder  had  been 
emptied.  "When  the  rupture  is  extraperitoneal,  dullness  appears  above 
the  pubes,  and  there  is  tenderness  and  rigidity. 

Infiltration  spreads  in  the  pelvis,  and  escapes  by  the  sciatic  notch 
into  the  buttock,  by  the  obturator  foramen  into  the  upper  part  of 
the  thigh,  or  along  the  inguinal  canal  into  the  scrotum.  Abscess 
formation  and  the  development  of  fistula?  follow,  and  then  throm- 
bosis and  septicaemia.  In  intraperitoneal  rupture  peritonitis  appears 
within  the  first  twelve  hours.  Death,  due  to  the  toxic  effect  of  the 
urine,  may  take  place  without  peritonitis. 

Diagnosis. — The  diagnosis  is  made  from  the  clinical  features 
detailed  above.  In  rupture  of  the  urethra,  blood  appears  at  the  meatus 
and  the  passage  of  a  catheter  is  obstructed.  In  rupture  of  the  kidney 
the  blow  is  in  the  lumbar  region,  the  loin  is  tender,  and  bladder 
irritation  is  absent.  In  fracture  of  the  pelvis,  retention  of  urine 
may  be  present  without  rupture,  the  diagnosis  being  made  by  passing 
a  catheter. 

The  injection  of  fluids  into  the  bladder  in  order  to  ascertain  if  a 
smaller  quantity  is  returned,  and  the  inflation  of  the  bladder  with  air 
which  will  escape  into  the  peritoneal  cavity  and  obliterate  the  liver 
dullness,  are  to  be  deprecated  as  they  disseminate  infection.  Except 
in  the  rare  case  of  partial  rupture,  cystoscopy  is  not  of  diagnostic 
value  since  it  is  impossible  to  distend  the  bladder.  Suprapubic 
exploration  of  the  bladder  is  the  most  satisfactory  diagnostic  method. 

Treatment. — Operation  should  be  performed  immediately, 
unless  the  shock  is  too  profound,  when  a  few  hours'  delay  is  permissible. 
When  the  diagnosis  of  intraperitoneal  rupture  is  established,  laparotomy 
is  performed,  the  urine  and  blocd  are  removed,  the  patient  placed 
in  the  Trendelenburg  position,  and  a  search  made  for  the  rupture. 
If  it  is  accessible  it  is  closed  by  catgut  sutures,  a  catheter  tied  in  the 
urethra,  and  the  peritoneum  drained.  If  the  wound  is  inaccessible  it 
will  only  be  possible  to  drain  the  peritoneum  and  tie  a  catheter  in 
the  urethra.  When  the  rupture  is  extraperitoneal  a  suprapubic  incision 
is  made,  the  rent  sutured,  and  the  bladder  drained. 


VESICAL    WOUNDS  859 

Results. — Cases  operated  <'i>   in  the   firsl    twelve   hours  have  a 
mortality  <>{  38  per  cent.,  while  those  operated  <ni  after  this  time  hi 
a  mortality  as  high  as  71  per  cent. 

Collected  cases  oi  extraperitoneal  rapture  with  urinary  infiltration 
have  .1  mortality  oi  83  per  cent.  (Mitchell). 

Wm  nds 

Bullet  wounds  oi  the  bladder  are  not  common,  and  stab  wounds 
with  a  bayonet  or  dagger  are  rare.     Accidental  wounds  during  surgical 

operations  are  met  with  when  the  bladder  is  drawn  into  a  hernial  - 
in  op. -ratio]!-  on  the  uterus,  and  in  symphysiotomy.  Falls  from  a 
height  and  impaling  of  the  bladder  from  the  perineum  are  nut  un- 
common. The  wound  is  complete  and  frequently  double  ;  it  may  be 
intra-  or  extraperitoneal.  Bladder  wounds  are  usually  complicated 
by  injury  to  the  bony  pelvis,  rectum,  uterus,  vagina,  urethra,  and 
intestine. 

Foreign  bodies — e.g.  fragments  of  clothing,  pieces  of  wood,  bullets 
— are  frequently  carried  into  the  wound,  and  infection  is  constant. 

Symptoms. — Shock  is  usually  present,  and  may  be  profound. 
There  are  pain,  tenesmus,  frequent  desire  but  inability  to  pass  wati 
a  few  drops  of  blood  may  be  passed  after  much  straining.  Urine 
mixed  with  blood  may  escape  from  the  wound,  but  this  may  be  pre- 
vented by  a  coil  of  small  intestine  plugging  the  wound  or  by  the  flow 
of  the  urine  into  the  peritoneal  cavity.  There  may  be  profuse  haemor- 
rhage from  the  wound.  "When  the  rectum  is  injured,  faeces  and  flatus 
escape  from  the  wound.  Spontaneous  closure  is  very  rare,  and  peri- 
tonitis almost  invariably  supervenes,  although  it  may  be  delayed  until 
the  separation  of  sloughs  on  the  seventh  or  eighth  day. 

In  extraperitoneal  wounds  where  the  wound  is  small  and  oblique 
there  is  perivesical  and  periurethral  extravasation  of  urine,  which 
becomes  infected,  and  this  is  followed  by  thrombosis  in  the  vesical 
and  prostatic  veins. 

Recto-vesical  or  vesico-vaginal  fistula,  or  fistula  on  the  surface  of 
the  abdomen,  scrotum,  perineum,  thighs,  or  buttocks,  is  very  common. 

Diagnosis. — The  escape  of  urine  from  the  wound  and  the  pres 
of  blood  in  the  urine  with  tenesmus  are  sufficient  to  establish  the 
diagnosis.      The  intra-  or  extraperitoneal  nature  of  the  wound   will 
usually  be  decided  by  operation. 

Treatment. — Laparotomy  should  be  performed  as  soon  as 
possible  when  there  is  a  wound  of  the  lower  part  of  the  abdomen. 
Wounds  of  the  bladder  and  intestine  are  searched  for  and  sutured. 
A'.,  extraperitoneal  wound  on  the  anterior  surface  of  the  bladder  may 
be  used  for  draining  the  bladder,  or  it  may  be  closed  and  a  catheter 
tied  in  the  urethra.     "When  the  bladder  has  been  wounded  from  the 


86o  THE   BLADDER 

perineum  the  wound  should  be  carefully  examined  and  free  drainage 
provided.  If  symptoms  of  peritonitis  supervene  the  abdomen  should 
be  opened. 

CYSTITIS 

Inflammation  of  the  bladder  is  due  to  the  combination  of  a  bacterial 
infection  with  some  factor  producing  lowered  resistance.  Rarely,  a 
virulent  type  of  bacteria  may  alone  cause  cystitis,  but  usually  some 
predisposing  factor  collaborates  by  producing  congestion  or  injury  of 
the  bladder  wall,  or  stagnation  of  the  urine  ;  the  most  common  are 
masturbation,  affections  of  the  female  genital  organs,  pregnancy, 
stricture,  enlarged  prostate,  calculus,  foreign  bodies,  malignant  growths, 
operations  upon  the  bladder,  atony  from  nervous  disease. 

Bacteriology. — Mixed  infection  is  frequent.  The  Bacillus  coli 
occurs  more  frequently  than  any  other  bacterium,  and  is  ofteu  found 
in  pure  culture.  The  following  bacteria  may  also  occur,  alone  or  in 
mixed  infections,  viz.  streptococcus,  staphylococcus,  proteus,  gono- 
coccus,  pneumococcus  of  Frankel  and  of  Friedlander,  Bacillus  pyo- 
cyaneus,  and  the  typhoid  bacillus.  In  chronic  cystitis,  anaerobic- 
bacteria  are  frequently  present.  The  bacteriology  varies  during  the 
course  of  either  an  acute  or  a  chronic  attack.  The  urine  is  acid  in 
cystitis  due  to  Bacillus  coli  and  the  gonococcus. 

Infection  may  occur  from  the  kidney  by  bacteria  borne  in  the 
urine  or  from  the  urethra  by  direct  spread  (gonorrhoea)  or  by  the 
passage  of  instruments  ;  bacteria  may  also  reach  the  bladder  through 
a  cystotomy  wound  or  a  fistula,  or  by  the  rupture  of  an  abscess  or  the 
formation  of  a  fistula  with  the  bowel. 

Pathological  anatomy  and  cystoscopic  appear- 
ances.— The  whole  surface  of  the  bladder  is  seldom  involved  in 
acute  cystitis.  The  base  is  frequently  affected  alone,  or,  less  often, 
an  area  of  cystitis  is  situated  at  the  apex  or  some  other  part  of  the 
organ.  Numerous  patches  may  be  distributed  over  the  bladder.  In 
severe  cystitis  and  in  chronic  cystitis  the  whole  surface  is  inflamed. 

The  capillary  vessels  are  engorged,  the  mucous  membrane  becomes 
reddened,  spongy  or  woolly,  and  the  outline  of  the  vessels  is  obscured. 
The  surface  is  bright  red.  and  the  mucous  membrane  is  thrown  into 
stiff  folds  and  ridges,  with  shreds  of  muco-pus  or  desquamated 
epithelium  adhering  to  it.  Haemorrhages  into  the  subepithelial  tissues 
may  occur.  If  the  haemorrhages  are  numerous  the  condition  is  known 
as  hemorrhagic  cystitis. 

In  bullous  cystitis  the  surface  is  covered  with  yellow  semitransparent 
bulla?.  Small  closely  grouped  granules  in  the  inflamed  mucous  mem- 
brane are  characteristic  of  follicular  cystitis.  In  cystic  cystitis  there 
are  yellow  sago-grain -like  follicles  which  are  either  scattered  or  grouped 


CYSTITIS  861 

together,  and  may  be  Buirounded  by  a  halo  of  inflammation.     Extensive 

phosphatic  deposi!  may  take  place.     Necrosis  oi  the  superficial  layers 

of  mucous  membrane  mixed  with  fibrin  forms  a  membrane  which  is 

off  in  th*'  condition  known  ae  croupous  or  diphtheritic  cystitis. 

infection  in  these  cases  is  usually  streptococcal. 

In  very  virulent  infections  exfoliation  of  the  mucou-  membrane 
may  take  place  and  the  necrosed  membrane  ionic  awa 
the  bladder.  Ulceration  is  usually  confined  to  the  superficial  1 
especially  along  the  summits  of  ridges  and  folds.  Less  frequently 
there  is  a  circumscribed  deep  round  or  oval  ulcer  with  a  heaped-up, 
sharply  cut  edge.  A  spreading  ring-like  ulcer  is  rarely  observed. 
Leucoplakia  is  found  in  chronic  cystitis.  In  chronic  cystitis  the  sub- 
mucosa  and  muscular  layers  are  infiltrated  and  sclerosed,  and  the 
perivesicular  fat  becomes  fibrous,  adherent,  and  greatlv  increased. 
The  bladder  contracts  and  the  cavity  is  permanently  diminished. 
Calculi  frequently  form  in  the  bladder  in  chronic  cystitis,  especially 
where  there  are  sacculi  or  residual  urine. 

Symptoms. — The  symptoms  are  frequent  micturition,  pain,  and 
changes  in  the  urine.  In  slight  cases  the  urine  is  passed  every  two 
hour-  and  there  is  some  urgency.  In  severe  cases  a  few  drops  of 
urine  are  passed  every  few  minutes,  active  incontinence  mav  be 
present,  and.  the  frequency  is  as  great  during  the  night  as  during 
the  day.  Polyuria  is  often  present.  There  is  pain  on  attempting  to 
hold  water,  and  scalding  pain  in  the  urethra  during  micturition  ;  in 
severe  cases,  cramping  pain  may  radiate  from  the  neck  of  the  bladder 
down  the  thighs  at  the  end  of  micturition.  Pyuria  is  always  present. 
The  pus  is  mixed  with  mucus  and  forms  a  slimy,  tenacious  deposit 
which  clings  to  the  bottom  of  the  receptacle.  Blood  is  present  in 
severe  cases  and  appears  at  the  end  of  micturition. 

Complications. — Retention  of  urine  may  occur,  especially 
where  obstruction  (stricture,  enlarged  prostate)  is  already  present. 
Ascending  infection  of  the  kidneys  is  a  serious  and  fatal  complication. 
Abscess  of  the  walls  of  the  bladder  or  in  the  perivesical  tissue  mav 
complicate  chronic  cystitis. 

Diagnosis. — 1.  Vesical  symptoms  may  be  caused  by  extra-urinary 
conditions  such  as  tabes,  hemorrhoids  and  anal  fissure,  pregnancv, 
ovarian  or  uterine  tumours,  and  prolapse  of  the  uterus.  Pyuria  is 
absent  in  these  cases. 

2.  Urinary  conditions  other  than  cystitis  may  cause  frequent 
micturition,  such  as  the  passage  of  large  quantities  of  urine  in  diabetes 
insipidus,  diabetes  mellitus,  and  hysterical  polyuria.  In  highly  acid 
urines,  oxaluria,  and  phosphaturia,  frequent  and  urgent  micturition 
with  pain  is  often  present,  but  pyuria  is  absent.  In  enlarged  prostate, 
stricture,  and  urethral  polypi,  frequency  of  micturition  may  be  present 


862  THE    BLADDER 

without  cystitis.  In  certain  diseases  of  the  kidney,  notably  tuberculous 
disease,  calculus,  and  pyelitis,  frequent  micturition  and  pyuria  may 
occur  without  cystitis. 

Is  the  cystitis  primary  or  secondary  %  Kenal  calculus,  pyonephrosis, 
renal  tuberculosis,  pyelonephritis,  and  urethral  or  prostatic  disease 
may  all  cause  secondary  cystitis.  The  diagnosis  is  made  by  the  history 
of  the  primary  infection  and  the  use  of  the  cystoscope  and  urethroscope. 

Prognosis. — In  uncomplicated  cystitis  the  attack  lasts  from 
two  to  five  weeks,  and  recovery  is  usually  complete.  When  a  diverti- 
culum or  sacculi  of  the  bladder  are  present,  recurrent  attacks  and 
eventually  chronic  cystitis  may  be  expected.  When  there  is  urethral 
obstruction  the  cystitis  rarely  disappears  until  the  obstruction  is 
completely  removed.  Cystitis  in  a  paralysed  bladder  is  permanent. 
When  the  cystitis  is  secondary  to  renal  disease  it  will  persist  until 
this  is  cured. 

Treatment.  Acute  cystitis. — The  patient  is  confined  to 
bed  and  placed  on  low  diet.  Diuretics  are  administered,  such  as 
Contrexeville  water,  barley-water,  parsley -tea,  and  buchu.  When  the 
urine  is  acid,  citrate  of  potash,  potassium  bicarbonate,  magnesium 
sulphate,  and  liquor  potassse  should  be  given,  and  sandalwood  oil 
added. 

To  relieve  spasm,  belladonna,  hyoscyamus,  opium,  and  bromide  of 
camphor  are  given,  and  hot  fomentations  applied  to  the  lower  abdo- 
men and  perineum.  Hot  sitz-baths  are  recommended  twice  or  thrice  a 
day,  and  relief  may  be  obtained  by  means  of  a  hot  rectal  enema  or 
a  vaginal  douche  containing  antipyrin.  The  bowels  should  be  opened 
with  a  saline  purge. 

No  attempt  should  be  made  to  wash  the  bladder  at  this  stage. 

Subacute  cystitis. — The  patient  is  allowed  up  and  a  less 
restricted  diet  permitted,  but  all  highly  spiced  foods,  curries,  much 
meat,  coffee,  and  all  alcoholic  drinks  are  forbidden. 

Urinary  antiseptics  such  as  urotropine,  hetralin,  helmitol,  urodonal, 
and  salol  should  be  administered,  and  sometimes  benzoate  of  soda 
and  ammonia  and  boric  acid  will  be  found  valuable.  If  the  cystitis  is 
due  to  Bacillus  coli  or  other  bacteria  which  flourish  in  acid  urine, 
alkalis  should  be  given,  but  if  the  urine  is  alkaline  from  ammoni- 
acal  decomposition,  dilute  mineral  acids,  boric  acid,  benzoate  of  soda 
and  ammonia,  and  especially  sodium  acid  phosphate,  are  indicated. 
Bladder-washing  should  be  commenced,  and  vaccine  treatment  with 
an  autogenous  vaccine  will  be  found  useful  (see  below). 

Chronic  cystitis.— If  renal,  prostatic,  or  urethral  disease  is 
present,  this  must  be  treated.  The  treatment  is  similar  to  that  of 
subacute  cystitis.  Bladder-washing  plays  a  prominent  part,  in  the 
treatment  ;  a  visit  to  one  of  the  Continental  spas,  such  as  Wildungen, 


CYSTITIS  863 

Oontrexeville,  01  Vittel,  Lb  frequently  of  greal  service.  Vaccine  treat- 
ment is  occasionally  beneficial  [see  below),  while  drainage  of  the 
bladder  with  daily  flushing  or  continuous  irrigation  may  become 
necessary. 

In  acid  cystitis  a  preliminary  washing  with  a  weak  alkali  rach 
as  bicarbonate  of  soda  (1  or  2  per  cent.)  is  useful,  while  in  very  alkaline 

•  vstitis  a  weak  solution  of  acetic  acid  (£  per  cent.)  may  be  employed. 
The  following  solutions  are  useful,  viz.:  potassium  permanganate, 
1  in  5,000  or  10,000;  oxycyanide  of  mercury,  1  in  1,000  or  5,000; 
biniodide  of  mercury,  1  in  10,000  or  20,000;  tincture  of  iodine,  \  to 
1  drachm  to  the  pint;   nitrate  of  silver,  1  in  2,000  or   L0,000. 

The  instillation  of  small  quantities  (i-2  drachms)  of  more  powerful 
solutions  is  sometimes  useful.  These  are  introduced  by  means  of  a 
small  syringe  and  catheter.  Iodoform  in  sterilized  liquid  paraffin 
(5  per  cent.),  gomenol  (5  to  20  per  cent.),  silver  nitrate  (2  per  cent.), 
and  protargol  (2  per  cent.)  may  be  used. 

In  intractable  subacute  and  chronic  cystitis  the  bladder  may  be 
drained  by  catheter  in  the  urethra,  ot  by  the  perineal  or  suprapubic 
routes. 

Serum  and  vaccine  treatment.' — In  acute  cystitis,  especi- 
ally if  due  to  the  Bacillus  coli  or  the  streptococcus,  serum-therapy 
may  be  useful.  The  serum  is  injected  subcutaneously,  and  a  large 
initial  dose  is  given  (20  c.c),  followed  by  smaller  doses  (10  c.c). 
Calcium  lactate  should  be  given  at  the  same  time  to  prevent  serum 
rashes  and  joint  troubles. 

Vaccine  treatment  is  most  suitable  for  cases  of  subacute  and  chronic 
cystitis.  The  patient  is  inoculated  with  an  autogenous  vaccine, 
commencing  with  small  doses  at  intervals  of  three  or  four  days,  rising 
slowly  to  higher  doses,  and  extending  the  interval  to  a  week  or  longer. 
A  reaction  should  be  avoided.  The  vaccine  of  Bacillus  coli  is  that  most 
frequently  used,  the  dosage  commencing  with  3  millions  or  less  of 
dead  bacteria,  and  rising  to  4,  5,  10,  15,  20,  and  so  on  to  100  and 
eventually  to  200  millions.  The  staphylococcus  is  given  in  doses 
commencing  at  100  millions,  and  rising  to  500  or  1,000  millions ;  and 
the  streptococcus  commences  at  2,  3,  5,  and  10  millions,  and  rises 
gradually  to  50  and  100  millions.  The  treatment  may  extend  over 
several  months. 

TUBERCULOUS   CYSTITIS 
Tuberculous  cystitis  may  be  "primary"  in  the  bladder,  or  secondary 
to  a  tuberculous  focus  in  the  kidney  or  the  male  genital  system. 

Etiology. — Vesical    tuberculosis    occurs    in    youth    and    early 
adult  life,  very  rarely  in  old  age,  and  is  more  common  in  men  than  in 
1  See  also  Vol.  I.,  pp.  90-108. 


864  THE    BLADDER 

women.  It  is  doubtful  whether  primary  tuberculous  cystitis  ever 
exists.  It  was  held  that  when  the  bladder  and  kidney  were  affected 
the  infection  was  primary  in  the  bladder  and  secondary  in  the  kidney 
(ascending)  ;  but  it  is  now  recognized  that  the  early  symptoms  of 
cystitis  are  usually  reflex,  the  bladder  being  non-tuberculous.  In 
cystitis  secondary  to  tuberculosis  of  the  kidney  there  is  either  direct 
spread  by  continuity  along  the  ureter  or  deposit  of  bacilli  from  the 
urine.  In  cystitis  secondary  to  genital  tuberculosis  in  the  male  the 
tuberculous  process  either  passes  directly  through  the  bladder  wall 
from  the  seminal  vesicles  or  prostate,  or  spreads  from  a  tuberculous 
prostatic  urethra  into  the  bladder. 

Pathology. — Greyish  tubercles  form  in  the  mucosa,  caseate, 
and  break  down  into  a  tiny  superficial  ulcer  with  sharply  cut 
edges.  Several  of  these  ulcers  may  run  together,  and  a  large  area 
of  bladder  wall  may  thus  be  ulcerated.  Deep  ulcers  may  also  form. 
Thev  are  round,  oval,  or  serpiginous,  with  a  greyish-red  granular 
base  and  a  deeply  undermined  edge.  Irregular  masses  of  granulation 
tissue  are  occasionally  seen.  In  old-standing  tuberculosis  the  bladder 
is  contracted  and  adherent  to  the  rectum  and  female  genital  organs, 
and  there  is  tuberculous  deposit  in  the  pelvic  lymph-glands.  Tuber- 
culous lesions  of  the  kidney  on  one  or  both  sides,  or  of  the  seminal 
vesicles  or  prostate,  are  also  present.  Tuberculosis  of  the  female  genital 
organs  is  rare. 

Symptoms. — Cystitis  arises  spontaneously  and  insidiously  in 
a  young  patient,  and  progresses  gradually  but  persistently.  Frequent 
micturition  is  the  earliest  symptom  ;  at  first  diurnal  and  moderate,  later 
it  becomes  nocturnal  also  and  the  intervals  much  less.  Micturition 
becomes  urgent,  and  urine  is  passed  every  quarter-  or  half -hour,  day 
and  night,  sometimes  involuntarily  during  heavy  sleep.  There  are 
vesical  pain,  urethral  scalding,  and  cramp-like  pain  at  the  end  of 
the  penis.  A  little  bright  blood  often  appears  at  the  end  of  micturi- 
tion.    Severe  attacks  of  hematuria  may  occur  at  intervals. 

Polvuria  is  present  and  is  due  to  tuberculous  changes  in  the  kid- 
neys. The  urine  is  pale  and  opalescent,  faintly  acid,  of  low  specific 
gravity,  and  contains  a  small  quantity  of  pus  well  mixed.  The  symp- 
toms are  unaffected  by  movement,  but  are  influenced  by  dietetic 
indiscretion  and  cold  damp  weather. 

Course  and  prognosis.- — If  septic  complications  are  avoided 
the  disease  is  slowly  progressive,  and  death  takes  place  after  some 
years  from  renal  failure  due  to  bilateral  renal  tuberculosis.  Fre- 
quently, however,  septic  complications  arise,  almost  invariably  as  the 
result  of  catheterization,  and  occasionally  secondary  stone  forma- 
tion follows.  Subacute  or  chronic  septic  pyelonephritis  eventually 
supervenes. 


TUBKKCULOUS   CYSTITIS  ^65 

Vesical  tuberculosis  secondary  to  unilateral  renal  tuberculosis 
may  disappear  after  nephrectomy,    When    the   disease   1-   secondary 

to  tuberculosis  of  the  seminal    vesicle    or  prostate  the   prognosis  is 
unfavourable. 

Diagnosis.  The  spontaneous  development  of  subacute  cystitis 
in  youth  or  early  adult  life  should  raise  the  suspicion  of  tuberculosis. 
The  appearance  of  the  urine,  the  discovery  of  the  tubercle  bacillus, 
and  the  result  of  inoculation  of  animals  are  important  in  diagnosis. 
Tuberculous  disease  may  be  found  in  the  genital  system  or  elsewhere 
in  the  body.  The  cvstoscope  shows  discrete  greyish-yellow  opaque 
tubercles  or  deep  tuberculous  ulceration.  Changes  at  the  ureteric 
orifice  and  grouping  of  tuberculous  inflammation  round  it  show  disease 
of  the  corresponding  kidney. 

Treatment. — Tuberculous  cystitis  secondary  to  unilateral  renal 
tuberculosis  generally  diminishes  or  disappears  after  nephrectomy. 
In  other  cases  further  or  different  treatment  is  necessary. 

General  treatment. — Residence  in  a  warm,  dry  climate,  such 
as  Egypt,  Algiers,  the  French  or  Italian  Riviera,  has  a  very  bene- 
ficial influence.  The  food  should  be  plain  and  nourishing ;  highly 
spiced  foods  and  alcoholic  drinks  should  be  avoided.  If  the  infection 
is  mixed,  urinary  antiseptics  should  be  used,  but  in  pure  tuberculosis 
they  have  no  effect.  Guaiacol  (5  minims  in  a  capsule  thrice  daily), 
cacodylate  of  soda  (J-l  gr.  hypodermically),  and  disodium  methyl 
arsenate  (|  gr.  hypodermically)  have  been  recommended.  Sandal- 
wood oil  is  useful  for  its  soothing  effect,  and  belladonna  and  hyos- 
cyamus  for  reducing  the  spasm  of  the  bladder. 

Tuberculin  should  be  given  in  all  cases,  and  very  striking  results 
are  frequently  obtained.  Pain,  frequency,  and  irritability  diminish, 
the  blood  disappears  from  the  urine,  and  the  patient  increases  in 
body  weight.  When  the  bladder  alone  is  affected  the  tuberculous 
process  may  disappear  completely.  When  the  cystitis  is  secondary 
to  renal  tuberculosis,  marked  improvement  is  observed  in  early  cases, 
but  relapses  occur.  In  genito-urinary  tuberculosis  the  results  are 
less  favourable,  but  amelioration  of  the  symptoms  may  be  antici- 
pated. The  treatment  should  begin  with  small  doses  {iwm  nig.  T.R.) 
and  be  very  slowly  increased  by  weekly  injections  to  tttoo  mg.  The 
treatment  extends  over  one  or  several  years. 

Local  treatment. — I  am  opposed  to  local  treatment  by  means  of 
bladder-washing  and  instillations.  Temporary  improvement  is  observed 
in  many  cases,  but  septic  complications  almost  invariably  supervene. 

The  following  local  treatment  has  been  used  :  The  bladder  is 
washed  with  boric  acid,  and  other  solutions  containing  antipyrin  or 
opium  to  soothe  pain.  Instillations  of  h-l  drachm  have  been  given 
with  Guyon's  svringe  :    corrosive    sublimate   (1  in  10,000  up  to  1  in 

3  d 


866  THE    BLADDER 

5,000),  iodoform  or  guaiacol  in  liquid  paraffin  (5  per  cent.),  gomenol 
(5  to  20  per  cent.),  picric  acid  (h  to  1  per  cent.)  have  been  used. 

Treatment  by  direct  application  of  nitrate  of  silver,  etc.,  may 
be  made  in  either  sex  through  Luys'  direct  cystoscope. 

In  the  very  rare  cases  of  a  solitary  ulcer  it  is  excised  by 
suprapubic  cystotomy.  In  other  cases  ulcers  have  been  curetted, 
or  cauterized  with  silver  nitrate,  chloride  of  zinc,  and  other  caustics, 
and  the  bladder  drained.  . 

SYPHILIS 

Syphilitic  disease  of  the  bladder  is  very  rare.  In  secondary  syphilis 
symptoms  of  acute  or  chronic  cystitis  may  develop.  On  cystoscopic  examina- 
tion there  is  congestion  and  swelling  of  the  mucous  membrane,  and  multiple 
t^mall  superficial  ulcers  with  indurated  edge  may  be  present.  In  tertiary 
syphilis  there  may  be  gummata  or  ulceration  of  the  bladder  wall.  The 
L'ummata  may  form  papillomas  which  are  indistinguishable  from  other  forms 
of  papilloma  except  that  they  disappear  under  antisyphilitie  treatment. 
In  other  cases  the  gumma  is  a  round  nodular  swelling  covered  with  ulcerated 
mucous  membrane.  The  symptom?  resemble  those  of  new  growth.  The 
lesions  disappear  rapidly  under  antisvphilitic  treatment. 

ACTINOMYCOSIS 

Actinomycosis  very  rarely  affects  the  bladder,  and  is  always  secondary 
to  intestinal  actinomycosis,  spreading  directly  to  the  bladder  from  the 
appendix  or  rectum.  Extensive  perivesical  inflammation  is  present,  and  there 
is  usually  a  perivesical  abscess.  The  symptoms  are  those  of  cystitis,  and  an 
indurated  mass  is  found  in  the  perivesical  tissue  and  round  the  appendix 
or  rectum.  The  diagnosis  can  only  be  made  by  the  discover}'  of  the  yellow 
actinomycotic  granules  in  the  urine.  The  treatment  consists  in  administering 
large  doses  of  iodide  of  potash  and  opening  collections  of  pus  if  they  exist. 
The  bladder  is  washed  with  urinary  antiseptics. 

TUMOURS 

Men  are  more  frequently  affected  by  tumours  of  the  bladder  than 
women,  usually  between  the  ages  of  40  and  60.  Vesical  growths  are 
rare  in  children  and  are  of  the  connective-tissue  variel 

Secondary  growths  result  from  the  spread  of  malignant  growths 
from  the  pelvic  organs.  In  the  rare  papillomatous  tumours  of  the 
renal  pelvis  or  ureter  new  growths  may  become  implanted  on  the 
bladder  mucous  membrane  or  spread  from  the  ureteric  orifice. 

Epithelial  C4rowths  :    Papilloma — Villous  Papilloma 

Pathology. — These  tumours  are  covered  with  villi,  and  are 
cither  sessile  or  pedunculated.  They  vary  in  size  from  a  split  pea  to 
a  Tangerine  orange,  and  are  single  (60  per  cent.)  or  multiple  (40  per 
cent.).  They  may  affect  any  part  of  the  bladder,  but  are  usually 
situated  at  the  base,  behind  and  to  the  outer  side  of  one  ureteric  orifice 
and  frequently  concealing  it.     Although  rarely  situated  on  the  trigone, 


VESICAL    PAPILLOMA 


they  frequently  surround  it  and  sometimes  the  urethra]  orifice.  Tin' 
papilloma  has  a  centra]  trunk  of  fibrous  tissue,  elastic  and  plain 
muscle  fibres,  and  blood-vessels,  from  which  branches  spread  oul  and 
subdivide.  (Kg.  548.)  The  epithelial  covering  is  transitional  in 
the  deeper  cylindrical  cells  radiating  in  characteristic  manner.  The 
nuclei  show  karyokinetic  figures,  and  there  is  abundant  variolation 
of  the  cells.  Small  villous  tumours  spring  up  <>n  the  mucous 
membrane  around  the  first  papilloma,  and  others  become  scattered 
over  the  bladder. 

These  growths  are  histologically  benign,  but  many  of  them,  in 
Bpite  of  their  histological  characters,  must  be  regarded  as  malig- 
nant for  these  reasons :  (1) 
They  spread  by  implantation. 
(2)  They  frequently  recur  after 
removal ;  the  recurrent  growth 
l-  multiple,  although  the  pri- 
mary growth  may  have  been 
single.  (3)  Multiple  growths 
become  sessile  and  irregular, 
and  in  a  large  number  of 
eventually  infiltrate  the  bladder 
wall. 

Symptoms.  —  Hematuria 
is  the  characteristic  and  usually 
the  only  symptom.  It  appears 
suddenly  without  an  apparent 
cause,  is  little  affected  by  rest, 
continues  for  one  or  two  mictu- 
ritions, or  for  a  day  or  a  week, 

and  suddenly  ceases.  The  blood  is  copious  and  well  mixed  with 
the  urine,  and  flat  or  irregular  clots  may  be  present.  After  a 
few  weeks,  months,  or  several  years  there  is  a  similar  attack  of 
haemorrhage.  The  attacks  recur  with  increasing  duration  and  dimin- 
ishing intervals.  Slight  aching  pain  in  one  kidney  is  frequently 
present. 

A  pedunculated  papilloma  may  obstruct  the  internal  meatus  and 
cause  retention  of  urine,  or  become  engaged  in  the  prostatic  urethra 
and  cause  Btrangury.    Clot  retention  from  excessive  haemorrhage  is  rare. 

Course  and  prognosis. — The  duration  may  extend  over 
many  years  (ten  to  twenty-rive  years),  during  which  there  is  incre 
in  size  and  multiplication  of  the  growth.  The  papilloma  may  remain 
>ingle  and  attain  a  large  size  ;  usually,  however,  multiple  tumour- 
are  found.  Recurrence  after  operation  is  common,  and  malignant 
transformation  frequently  takes  place. 


Fig.  54S. — Papilloma  of  bladder 
(cystoscopic  view). 


868  THE    BLADDER 

Diagnosis. — Symptomless  hsematuria  in  a  young  or  middle- 
aged  adult  is  usually  due  to  papilloma  of  tlie  bladder,  to  "  essential  " 
renal  hematuria,  or  to  early  renal  growth. 

The  presence  of  tube  casts  and  renal  colic  from  the  passage  of 
clots  indicates  a  renal  source.  Portions  of  vesical  papilloma  may 
be  passed  in  the  urine,  or  may  be  removed  in  the  eye  of  a  catheter. 
The  diagnosis  is  made  with  the  cystoscope. 

Cystoscopy.— A  papilloma  is  seen  as  a  sessile  or  pedunculated, 
round  or  irregular  tumour,  with  tendrils  of  varying  length,  which  float 
in  the  fluid  medium.  A  leash  of  vessels  passes  up  to  the  growth  from 
the  trigone.     A  large  growth  may  obscure  the  cystoscope  light. 

Treatment.  1.  Non-operative. — Daily  instillations  for  six 
months  of  2  oz.  of  nitrate  of  silver  solution  (1  in  3,500  at  100°  F.) 
or  resorcin  (2  per  cent.),  by  means  of  a  Guyon's  syringe,  have 
been  advocated  by  Casper  and  others.  Necrosis  of  the  tumours  has 
apparently  occasionally  followed. 

2.  Operative,  (a)  Removal  through  the  urethra  ("  intravesical  opera- 
tion ''"). — This  is  carried  out  by  means  of  a  Nitze  operating  cystoscope 
or  by  Luys'  direct  cystoscope,  or  in  the  female  through  the  Luys  or 
Kelly  cystoscope.  The  papilloma  is  snared  by  a  fine  platinum  wire, 
and  left  in  the  bladder  to  be  expelled  with  the  urine.  Many  sittings 
may  be  required,  small  portions  being  snared  at  a  time.  The  growths 
must  be  favourably  situated  for  easy  access.  Subsequent  haemorrhage 
is  sometimes  severe.  Good  results  have  been  obtained  with  small 
easily  accessible  growths  by  some  surgeons.  The  mortality  in  Wein- 
rich's  collected  cases  was  1  in  150,  and  71  per  cent,  had  no  recurrence 
after  three  or  four  years. 

(b)  Removal  by  open  operation. — This  should  be  adopted  in  all  cases. 
If  multiple  papillomas  are  present  a  chart  showing  their  number  and 
position  should  be  drawn  at  a  preliminary  cystoscopy.  Suprapubic 
cystotomy  is  performed,  and  the  patient  placed  in  the  Trendelenburg 
position.  The  growths  are  fully  exposed  by  proper  retractors  and  a 
powerful  head-lamp.  With  special  scissors  and  forceps  the  growth  is 
removed  with  the  mucous  membrane  on  which  it  is  set,  the  cut  edges 
stitched  together,  and  the  interior  of  the  bladder  treated  with  silver 
nitrate  solution  (4  to  6  per  cent.),  and  drained  with  a  large  suprapubic 
tube. 

For  some  years  after  the  operation  the  bladder  must  be  inspected 
at  intervals  for  recurrence.  At  the  earliest  appearance  of  a  recurrent 
bud  of  papilloma  it  should  be  destroyed  with  the  electric  cautery 
through  Luys'  direct  cystoscope. 

When  the  bladder  is  rilled  with  large  masses  of  papillomatous 
growth  the  contents  should  be  cleared  out,  and  the  hot  douche, 
cautery,  adrenalin,  or  other  means  used  for  stopping  the   bleeding. 


MALIGNANT   DISEASE  869 

In  Bome  cases  total  cystectomy  after  ureterostomy  is  tl oly  opera- 
tion which  holds  a  prospect  of  cure  Owing  to  tin-  lii-h  Iimiikm liat »■ 
mil  remote  mortality,  cystectomy  can  [only  be  adopted  in  very 
tare  cases. 

Results. — The  mortality  of  open  radical  operations  for  papilloma  of 
the  bladder  is  very  small  under  modern  conditions.  In  Ratins  statistics  there 
mis  a  mortality  of  3-S  per  cent,  in  150  cases.  Recurrence  of  papilloma  took 
place  in  28  per  cent.  With  more  thorough  operations  better  results  can  be 
obtained. 

Adenoma  of  the  bladder  is  a  rare  tumour  arising  in  the  glands  at 
the  base.     It  may  be  diffuse  or  circumscribed. 

Cholesteatoma  consists  in  a  great  thickening  of  the  epithelium, 
which  becomes  squamous  and  pearly  in  appearance.     It  is  very  rare. 

Carcinoma 

A  number  of  malignant  growths  differing  widely  in  their  gross 
and  microscopic  characters  are  grouped  under  this  head,  viz.  malignant 
papilloma,  nodular  and  infiltrating  growths. 

1.  Malignant  papilloma. — A  papillomatous  tumour  may  be  malig- 
nant from  an  early  stage  of  development,  or  it  may  have  the  characters 
of  a  simple  villous  tumour  for  many  years  and  then  become  malignant. 

In  a  malignant  growth  the  villi  are  stunted  and  irregular  in  size 
and  shape,  and  the  tumour  is  irregular  in  contour  and  sessile.  The 
bladder  wall  becomes  infiltrated  and  the  mucous  membrane  at  the 
base  of  the  tumour  adherent  to  the  submucous  tissue.  Microscopically 
there  is  rapid  and  irregular  proliferation  of  the  epithelium,  and  the 
base  shows  the  invasion  of  lymphatic  spaces  and  veins  by  irregular 
masses  of  cells.  ■ 

2.  Nodular  growths. — These  are  sessile,  rarely  pedunculated,  irre- 
gular, nodular  or  smooth,  and  varying  in  size  from  a  hazel-nut  to  a 
Tangerine  orange.  Occasionally  there  is  a  round  tumour  with  a  flat 
or  depressed  surface  showing  stunted  villi.  These  tumours  belong  to 
the  papillomatous  group,  and  consist  of  a  mass  of  irregular  villi 
closely  matted  together,  and  sometimes  necrotic  on  the  surface.  In 
the  deeper  part,  masses  of  cells  infiltrate  the  muscular  planes,  passing 
along  the  lymphatic  vessels. 

3.  Infiltrating  grouihs. — The  growth  forms  flat  nodules  on  the  surface, 
but  its  greatest  extent  is  intramural.  It  may  take  the  form  of  a  hard, 
depressed  ulcer  surrounded  by  nodules  or  by  a  raised  hard  ring  of 
growth.  The  histological  structure  varies  as  follows,  viz. : — (a)  Epithe- 
lioma :  Squamous  epithelioma  (chancroid)  with  cell  nests  develops  in 
a  patch  of  leucoplakia.  (b)  Cylindrical  epithelioma  or  adeno-carcinoma 
develops  in  the  tubular  glands  at  the  base  of  the  bladder  and  is  rare, 
(c)  Spheroidal-celled  carcinoma  :    This  forms  a   soft  or  hard  tumour 


S7o  THE    BLADDER 

according  to  the  proportion  of  fibrous  stroma.     It  consists  of  alveoli 
of  varying  sizes,  filled  with  spheroidal  cells. 

Malignant  growths  of  the  bladder  remain  for  a  long  time  localized 
to  the  viscus.  Perivesical  spread  may  be  extensive,  and  early  penetra- 
tion is  a  feature  of  some  growths.  Adhesions  to  the  vagina,  uterus, 
rectum,  and  intestines  form,  and  perforation  may  occur.  Spread 
along  the  lymphatics  follows  the  lymphatic  trunks.  In  the  latest 
stages  metastatic  deposits  are  found  in  the  lungs,  pleura,  liver, 
spleen,  and  kidneys. 

Symptoms. — Hsematuria  is  the  most  frequent  (9Q"2  per  cent.) 
and  the  earliest  symptom.  A  little  blood  appears  at  the  end  of  mic- 
turition ;  at  first  intermittent,  it  later  becomes  constant,  and  there- 
may  be  intercurrent  severe  attacks  of  haemorrhage. 

Frequent  micturition  occurs  in  68  per  cent,  of  cases,  and  may  be 
the  initial  symptom.  It  is  nocturnal  as  well  as  diurnal,  and  is  usually 
due  to  cystitis,  although  it  may  occur  without  cystitis  and  with  a 
clear  urine. 

Pain  is  due  to  cystitis,  to  obstruction  by  blood  clot,  or  to  pressure 
on  nerves.  It  is  felt  along  the  urethra,  at  the  end  of  the  penis,  in  the 
suprapubic  region  and  groin,  in  the  perineum,  anus,  and  down  the 
thighs  or  along  the  sciatic  nerve.  The  urine  sometimes  contains  a 
persistent  excess  of  epithelial  bladder  cells,  and  portions  of  the  growth 
may  be  passed.  Flat  or  limpet-shell-shaped  phosphatic  concretions 
may  form  on  ulcerated  patches  and  be  discharged  with  the  urine. 
Emaciation  is  present  in  advanced  cases. 

Diagnosis. — There  are  two  clinical  types— (1)  cystitic  (40  per 
cent.),  (2)  hseniaturic  (60  per  cent.).  Cases  belonging  to  the  cystitic 
type  may  be  mistaken  for  stone,  simple  enlargement  of  the  prostate, 
or  malignant  disease  of  the  prostate.  The  diagnosis  is  made  by  rectal 
examination  and  cystoscopy.  The  hsematuric  type  must  be  distin- 
guished from  simple  papilloma  or  tuberculous  disease  by  examination 
of  the  urine  for  the  tubercle  bacillus  and  by  cystoscopy. 

Course  and  prognosis. — The  average  duration  of  life  after 
the  first  appearance  of  symptoms  is  under  three  years.  Septic  cystitis 
and  ascending  pyelonephritis  is  the  usual  cause  of  death.  Radical 
operations  in  the  early  stages  give  an  increasingly  favourable  prospect 
of  cure  (see  below). 

Treatment. — Radical  operation  should  be  undertaken  if  the 
growth  is  confined  to  the  bladder  and  the  patient  sufficiently  robust. 
It  is  contra-indicated  by  renal,  pulmonary,  or  circulatory  inadequacy. 
The  radical  operations  are — (1)  resection  of  the  bladder  wall,  (2) 
cystectomy. 

1.  Resection  is  preferred  wherever  possible,  as  the  mortality  is 
.10  per  cent,  compared  with  40  per  cent,  in  cystectomy.     The  follow- 


MALIGNANT   DISEASE  871 

ing  conditions  are  unsuitable  for  resection,  though  they  do  nol  contra- 
indicate  cystectomy,  viz.  (1)  very  extensive  growths  confined  to  the 
bladder,  (2)  rapidly  growing  malignanl  papilloma,  (•">)  growl  bs  involving 

both  ureters,  the  trigone  or  urethra,  (1)  intractable  cystitis. 

Free  exposure,  the  Trendelenburg  position,  and  good  illumination 

are  necessary.  The  area  of  the  bladder  wall  with  the  perivesical  fat 
giving  a  margin  of  an  inch  all  round  the  growth  is  removed.  If  tin- 
includes  the  ureteric  orifice  the  ureter  is  implanted  into  the  upper 
part    of  the   bladder  wound. 

2.  Cystectomy. — The  ureters  must  first  be  transplanted  and  the 
bladder  removed  at  a  subsequent  operation.  Implantation  into  the 
rectum,  large  intestine,  urethra,  vagina,  skin  of  the  loin,  or  suprapubic 
wound,  or  bilateral  nephrostomy,  has  been  performed.  Implantation 
into  the  vagina  in  the  female  and  into  the  skin  in  the  male  has  given 
the*  best  results.  In  the  male,  cystectomy  is  performed  by  a  combined 
perineo-abdominal  method.  The  posterior  surface  of  the  prostate 
and  seminal  vesicles  is  first  exposed  by  a  curved  prerectal  incision. 
The  patient  is  then  placed  in  the  Tredelenburg  position,  and  the  bladder 
exposed  suprapubically.  The  peritoneum  is  stripped  off,  the  ureter 
and  large  vessels  exposed  and  clamped,  and  the  bladder  raised  and 
detached  from  the  prostate.  The  prostate  may  be  removed  with  the 
bladder  (cysto-prostateetomy). 

In  the  female  (Pawliks  operation)  the  ureters  are  exposed  from 
the  vagina,  cut  across  and  implanted  in  the  vaginal  wall,  and  after 
some  weeks  the  bladder  is  exposed  and  removed  by  a  suprapubic 
operation.  The  urethra  is  implanted  into  the  vagina,  the  outlet  of 
which  is  closed.     The  vagina  forms  a  reservoir  for  the  urine. 

Results  of  operation. — In  30  cases  in  which  I  resected  the 
bladder  Avail  for  malignant  growth,  there  were  3  deaths  (10  per  cent.).  In 
10  of  these,  one  ureter  was  transplanted.  Watson  collected  96  cases,  with 
a  mortality  of  21*8  per  cent.  Kiimmel  found  that  of  47  cases  10  were  well 
sixteen,  fifteen,  eight,  and  six  and  a  half  years  after  operation.  In  39  cases 
of  cystectomy  collected  from  the  literature  the  operative  mortality  was 
46 "1  per  cent.  Only  10  cases  could  be  traced,  and  in  but  2  of  these  was  the 
period  longer  than  fifteen  months  ;  one  was  above  five  years  (Hogge)  and 
one  sixteen  years  (Pawlik). 

Palliative    treatment This  is  adopted  when  radical  operation 

is  contra-indicated. 

Hcematuria. — The  patient  is  confined  to  bed.  and  the  foot  of  the 
bed  is  raised.  Opium,  ergot,  and  calcium  lactate  are  given.  The 
bladder  is  washed  with  large  quantities  of  hot  silver-nitrate  solution 
(1  in  10,000),  continuous  irrigation  being  made  through  a  double-way 
catheter.  This  is  followed  by  the  instillation  of  a  little  adrenalin 
solution  (1  in  1,000).  If  the  bladder  is  distended  with  clot  an 
attempt  should  be  made  to  remove  the  clot  by  means  of  an  evacuating 


872  THE   BLADDER 

cannula  and  bulb,  and,  this  failing,  the  bladder  should  be  opened 
supra pubically,  the  clots  cleared  out,  and  a  large  rubber  drainage- 
tube  inserted.     Partial  operations  sometimes  relieve  severe  bleeding. 

Pain. — Suppositories  of  extract  of  belladonna  (£  gr.)  and  morphia 
(£  gr.),  to  which  cocaine  (J-l  gr.)  may  be  added,  or  the  injection  of 
tincture  of  opium  (20  minims)  with  antipyrin  (30  gr.)  in  hot  water 
as  an  enema,  may  give  relief.  "Washing  the  bladder  with  silver- 
nitrate  solution  may  be  beneficial,  and  if  the  urine  is  alkaline  and 
pkosphatic  material  is  being  deposited,  sodium  acid  phosphate  (20  gr. 
thrice  daily)  and  urinary  antiseptics  should  be  given.  Washing 
with  a  very  weak  solution  of  acetic  acid  often  gives  relief.  Supra- 
pubic cystotomy  may  become  necessary,  and  is  followed  by  continuous 
irrigation,  a  permanent  suprapubic  drain  being  established. 

Partial  operations  may  relieve  pain,  but  should  be  avoided  when 
severe  cystitis  is  present. 

Nephrostomy  after  ligature  of  the  ureter  (Watson),  ureterostomy, 
or  implantation  of  the  ureter  in  the  loin  on  one  side  with  nephrectomy 
(Harrison),  or  on  both  sides  (Fenwiek),  may  be  used  in  inoperable 
carcinoma  of  the  bladder  with  great  pain. 

Connective-Tissue  New  Growths 
Sarcoma  of  the  bladder  is  found  in  infancy  and  late  adult  life, 
but  is  rare.  The  growth  arises  in  the  submucous  or  in  the  perivesical 
areolar  tissue,  or  rarely  from  the  intramuscular  connective  tissue  ; 
it  is  situated  on  the  posterior  or  lateral  walls.  The  tumour  is  pedun- 
culated or  sessile  and  infiltrating.  The  bladder  cavity  may  be  filled 
with  polypoid  masses,  and  the  wall  infiltrated  with  growth.  The 
urethra  is  sometimes  blocked,  and  the  polypoid  masses  may  appear 
at  the  external  meatus  in  the  female. 

The  varieties  are  spindle-celled,  round-celled,  melanotic,  myxo- 
sarcoma, rhabdo-myoma,  and  chondro-sarcoma. 

Other  connective-tissue  tumours,  such  as  myoma,  myo-fibroma, 
and  myxoma,  are  only  rarely  found.  Dermoid  cysts  have  been 
described. 

VESICAL   CALCULUS 

Etiology. — The  etiology  of  stone  formation  in  the  urinary 
tract  is  discussed  under  Renal  Calculus  (p.  832). 

Stone  in  the  bladder  is  less  frequent  in  children  than  in  adults, 
and  much  more  frequent  in  men  (especially  old  men)  than  in  women. 
Calculi  are  "  primary "  when  they  form  in  an  aseptic  urine,  and 
"  secondary  "  when  they  result  from  bacterial  changes  in  the  urine. 
The  nucleus  may  be  formed  by  a  small  oxalate-of-hme  or  uric-acid 
calculus  descended  from  the  kidney,  or  a  portion  of  blood  clot,  a 
fragment  of  a  catheter,  a  pin,  a  silk  ligature,  a  fragment  of  necrosed 


VESICAL   CALCULUS  873 

bone,  or  other  foreign  body  in  the  bladder.  The  two  importanl  pre- 
disposing factors  in  the  production  of  secondary  calculi  are  bacterial 
action  and  stagnation  of  urine.  This  combination  is  frequently  found 
in  old  men  with  enlarged  prostate  and  cystitis. 

Pathology.     Vesical  oalculi  are  formed  of  uric  acid,  phosphate 

oxalate  of  lime,  in  that  order  of  frequency,  and  rarely  of  cystin.  indigo,  or 
calcium  carbonate. 

Uric-acid  calculi  (Fig.  .549,  1-3)  may  consist  of  pure  uric  arid  nr  of  am- 
monium or  sodium  mates.  They  are  single  or  multiple,  rounded,  oval,  or 
flat.  The  surface  is  smooth  or  finely  nodular  and  easily  polished.  They  are 
sandy-yellow  to  dark-brown,  show  regular  concentric  lamination,  and  are 
of  hard  consistence.  Qxalate-of-lime  calculi  (Fig.  549,  6)  are  usually  single, 
vary  from  a  pea  to  a  chestnut  in  size,  and  have  a  dark-brown  colour.  The 
surface  is  covered  with  closely  set  conical  bosses  (mulberry  calculus)  or  a  few 
sharp  projecting  spines  (star  form).  They  are  very  hard,  and  on  section 
show  irregularly  disposed  lamina?.  Phosphatic  calculi  (Fig.  549,  4,  7)  con- 
sist of  basic  calcium  phosphate,  alone  or  mixed  with  ammonio-magnesium 
phosphate,  and  perhaps  with  ammonium  urate.  They  are  soft  and  crumb- 
ling, but  when  crystalline  are  very  hard.  On  section,  they  are  granular  and 
rarely  show  lamination.  Cystin  calculi  are  oval,  granular,  yellowish-brown, 
have  a  soapy  appearance,  and  turn  greenish-yellow  when  exposed  to  air. 
Xanthin  stones  are  smooth  and  yellow,  and  indigo  are  blue,  while  calcium 
carbonate  are  greyish-white,  earthy-looking,  hard  stones.  Calculi  are  rarely 
composed  of  a  single  ingredient. 

Phosphatic  stones  develop  rapidly,  a  large  stone  forming  in  a  few  weeks. 
Uric-acid  calculi  form  less  rapidly,  and  oxalate  stones  require  some  years  to 
reach  moderate  size. 

Vesical  calculi  may  be  movable  or  may  be  fixed  in  diverticula  (Fig.  549,  8) 
or  saccules,  or  in  the  ureteral  or  urethral  orifices.  A  stone  may  be  spas- 
modically grasped  in  the  upper  part  of  the  bladder,  or  may  be  wedged 
behind  an  enlarged  prostate. 

Multiple  stones  may  be  present  to  the  number  of  400  or  500. 

Cystitis  may  precede  the  development  of  a  calculus,  or  result  from  its 
presence.  Papilloma  or  malignant  growth  rarely  complicates  stone.  Chronic 
pyelonephritis  is  the  usual  cause  of  death. 

Symptoms. — There  may  be  preceding  attacks  of  renal  colic 
when  the  stone  or  its  nucleus  has  descended  from  the  kidney.  Fixed 
and  very  large  calculi  are  "  latent/' 

Frequent  micturition  and  discomfort  after  micturition  are  the 
earliest  and  most  common  symptoms.  The  frequency  of  micturition 
is  absent  at  night  unless  severe  cystitis  is  present.  Pain  is  felt  in 
the  neck  of  the  bladder  and  is  referred  to  the  end  of  the  penis  ;  it 
is  sharp  and  cutting,  and  is  experienced  at  the  end  of  micturition. 
Hematuria  is  frequently  present.  It  is  slight,  and  appears  at  the 
end  of  micturition,  and  the  blood  is  bright.  An  intermittent  stream 
is  sometimes  observed,  and  complete  retention  may  occur.  All  the 
svmptoms  of  stone  are  aggravated  by  jolting  movements  and  improved 
by  rest. 

The  urine    contains   crystals    of    oxalate    of    lime,    uric    acid,    or 


Fig.  549. — Collection  of  vesical  calculi. 

i-;,    Large   uric-acid   calculi;   4,  collection  of  disc-shaped  phosphatic   calculi;  5,    calculus 

formed    on     silk    suture;     6,     mulberry    calculus    (oxalate  of    lime);     7,   large    phosphatic 

calculus  ;    8,    phosphatic  calculus   from  diverticulum  ;     0.  collection    of  vesical    calculi    in 

enlarged  prostate 


S74 


VESICAL    CALCULUS 

phosphates,  microscopic  quantities  of  blood,  an  excess  of  leuco 
and  usually  some  epithelial  cells.  En  children,  screaming  on  micturi- 
tion and  retention  of  urine  are  uot  infrequent,  or  there  may  be  active 
incontinence  of  mine  In  Bmall  boys  "milking"  of  the  penis' to 
ease  the  pain  Leads  to  an  enlarged,  turgid,  semi-ereel  condition  of 
the  organ  which  ia  very  characteristic.  When  cystitis  complicates 
stone  the  frequency  of  micturition  liiT.mii'>  nocturnal  as  well  as 
diurnal,  the  pain  is  increased,  and  pus  and  mucus  appear  in  the  urine. 
which  frequently  becomes  alkaline  and  stinking. 

In  old-standing  eases  symptoms  of  ascending  pyelonephritis  appear, 
and  the  patient  shows  signs  of  "  urinary  septicaemia." 

Diagnosis. — The  severity  of  the  pain  and  its  sharp  character,  the 
diurnal  frequency,  and  the  pronounced  effect  of  movemenl  and  jarring 
on  all  the  symptoms,  are  characteristic  of  calculus.  The  previous 
_re  of  a  stone  or  past  operations  for  stones  are  important  points. 
Fixed  stones  do  not  produce  the  characteristic  symptoms.  Rectal 
and  vaginal  examination  usually  fails  to  detect  the  stone.  "When  the 
calculus  is  large  it  may  be  detected  bimanually,  especially  in  children. 

The  bladder  is  examined  with  a  sound  after  introducing  a  few 
ounces  of  fluid,  and  the  impact  of  the  metal  instrument  on  the  stone 
gives  a  characteristic  sensation  and  sound.  In  children  the  stone 
lies  at  the  neck  of  the  bladder,  in  adults  behind  the  trigone,  and  in 
old  men  frequently  behind  an  enlarged  prostate.  The  ridges  of  a 
trabeculatecl  bladder,  phosphatic  deposit,  and  new  growths  may  give 
rise  to  difficulties  in  diagnosis  with  the  sound,  and  care  should  be 
taken  that  the  handle  does  not  come  in  contact  with  a  ring  or  button. 

A  small  stone  may  be  detected  by  using  a  lithotrity  evacuator 
and  bulb. 

Cystoscopy  is  the  most  certain  method  of  detecting  a  calculus. 
and  is  especially  useful  in  fixed  calculi.  Radiography  shows  a  shadov 
in  the  vesical  area. 

Treatment. — A  small  calculus  may  sometimes  be  removed  by 
means  of  the  cannula  and  aspirator  used  in  litholapaxy. 

The   operations  performed  for  stone   in  the   bladder  are   of  two 
3,    viz.  :    (1)  Crushing    (litholapaxy    or    lithotrity),    (2)  cutting 
(lithotomy). 

Litholapaxy  or  lithotrity — The  modern  operation  of  lithola- 
paxy (Bigelow,  1878)  consists  in  crushing  a  stone  and  removing  the 
fragments  at  one  sitting.  Four  or  five  ounces  of  boric  solution  are 
introduced  into  the  bladder;  the  lithotrite  is  passed,  the  handles  are 
raised,  the  blades  separated.  The  stone  rolls  in  between  the  blades  and 
is  caught.  The  blades  are  now  locked  and  the  male  blade  screwed 
home,  and  this  manoeuvre  is  repeated  until  all  the  fragment 
crushed,  when  the  lithotrite  is  removed.   A  large  cannula  is  now  p 


S76  THE    BLADDER 

and  the  aspirator  bulb  applied.     By  alternate  compression  and  relaxa 
tion  the  fragments  are  swept  into  the  bulb  and  fall  by  their  weight 
into  the  glass  bulb.     When  all  the  fragments  have  been  removed  the 
bladder  is  washed  with  weak  nitrate-of-silver  solution  and  a  catheter 
tied  in  the  urethra  for  a  few  days. 

Litholapaxy  has  been  performed  upon  young  children.  The 
voungest  child  on  whom  it  has  been  done,  a  boy  of  fifteen  months, 
was  under  the  author's  care. 

Difficulties  and  contra-indications. — Litholapaxy  is  contra-indicated 
by  (1)  severe  and  persistent  cystitis,  (2)  considerable  enlargement 
of  the  prostate,  (3)  advanced  sacculation,  (4)  fixed  calculi.  (5)  spas- 
modic contraction  of  the  bladder,  (6)  new  growths  of  the  bladder 
complicating  stone,  (7)  very  large  and  hard  stones. 

L'rethral  stricture  or  a  narrow  meatus  should  be  treated  before 
litholapaxy  is  performed. 

Perineal  litholapaxy,  through  a  median  external  urethrotomy 
wound,  has  been  performed,  but  it  is  inferior  to  litholapaxy  and  to 
suprapubic  lithotomy. 

Dangers. — Ascending  pyelonephritis  and  perforation  of  the  bladder 
wall  are  rare.  A  rise  of  temperature  may  occur  when  cystitis  is  pre- 
sent, and  is  avoided  by  careful  preparation  of  the  bladder  and  by 
tying  in  a  catheter  and  washing  the  bladder  after  the  operation. 

Suprapubic  lithotomy. — The  bladder  is  distended  with  fluid 
and  opened  suprapubicallv,  and  the  stone  removed  by  lithotomy 
forceps  or  a  scoop.  If  the  prostate  is  enlarged,  prostatectomy  is 
now  performed. 

Median  perineal  lithotomy. — The  patient  is  placed  in  the 
lithotomy  position,  and  the  membranous  urethra  opened  on  a  staff 
by  a  median  perineal  incision. 

The  forefinger  is  introduced  along  a  gorget  into  the  bladder,  and 
a  pair  of  lithotomy  forceps  or  a  scoop  passed  alongside  this  and 
the  stone  removed.  A  rubber  perineal  drainage-tube  is  tied  in  the 
bladder  for  some  days. 

Lateral  lithotomy  is  now  abandoned  in  favour  of  one  of  the 
methods  here  described. 

Vaginal  lithotomy  consists  in  opening  the  bladder  base  behind 
the  trigone  on  an  instrument  introduced  through  the  urethra,  and 
removing  the  stone  with  lithotomy  forceps.  Vesico-vaginal  fistula  is  a 
frequent  sequel. 

Results  of  operation.— The  results  in  1.670  cases  of  stone  in  the 
bladder  operated  on  at  St.  Peter's  Hospital  in  the  years  1864-1910  showed 
a  mortality  in  the  first  decade  of  15-2o  per  cent.,  and  of  3-36  per  cent,  in  the 
last  decade. 

The  death-rate  of  litholapaxy  varies  from  2  per  cent.  (Legueu)  to  3-6  per 
cent.  (Zuckerkandl). 


FOREIGN    BODIES   IN   THE   BLADDER 

In  the  practice  of  surgeons  who  perform  lithotrity,  suprapubic  or  perineal 
lithotomy  Bhows  a  high  death-rate,  as  all  the  gravi  L  in  this 

way.  Thus,  Prayer's  statistics  Bho'w  a  perineal  lithotomy  mortality  of  18*2 
and  a  suprapubic  lithotomy  mortality  of  12*75  i»-i  cent.  When,  however, 
the  same  cases  are  treated  in  the  two  operations,  the  results  are  leas 
disproportionate,  Assenfeldt,  in  460  cases  of  suprapubic  lithotomy,  found 
tk  death-rate  <>f  ;>■<>  per  t-t-nt . 

FOREIGN    BODIES 

ign  bodies  reach  the  bladder  by  the  urethra  or  through  the  bladder 
wall.  They  may  result  from  surgical  operations.  Silk  ligatures  used  la 
operations  upon  the  bladder  or  pelvic  viscera,  or  tin-  flexible  guidi 
urethrotome,  are  examples.  Foreign  bodies  are  frequently  introduced  by 
the  patient.  The  mucous  membrane  becomes  inflamed  at  the  points  "i 
contact  with  the  foreign  body,  and  ulceration  and  even  penetration  of  the 
bladder  wall  may  follow.  The  foreign  body  becomes  encrusted  with  phos- 
phatic  deposit,  and  a  large  phosphatic  stone  is  formed.  Tin-  Bymptoms  are 
similar  to  those  of  stone  in  the  bladder,  and  the  diagnosis  is  made  from  the 
history,  by  radiographic  examination,  and  by  cystoscopy. 

Treatment. — Urethral  operations  are  most  suitable  in  the  female 
subject,  but  are  also  feasible  in  some  cases  in  the  male.  In  the  female  a 
large  Kelly's  tube  is  used  after  dilatation  of  the  urethral  orifice,  and  the 
patient  placed  in  the  Trendelenburg  position.  The  foreign  body  is  seized 
with  fine  forceps  and  removed,  a  finger  in  the  vagina  assisting  the  manoeuvre. 
In  the  male,  Luys'  direct  cystoscope  should  be  used.  When  these  methods 
fail  (50  per  cent.)  the  bladder  is  opened  suprapubicallv.  the  foreign  body 
removed,  and,  unless  severe  cystitis  with  ulceration  is  present,  the  wound  is 
closed. 

PERICYSTITIS   AND    PERIVESICAL   ABSCESS  , 

Etiology. — Pericystitis  may  be  secondary  to  disease  or  injury  of 
the  bladder,  or  it  may  arise  in  the  neighbouring  organs  or  structures,  such 
as  the  urethra,  rectum,  prostate,  appendix,  or  pelvic  bones.  Men  are  more 
frequently  affected  than  women.  Two  forms  are  recognized:  (1)  Chronic 
fibro-lipomatous  pericystitis  with  or  without  points  of  suppuration ;  the 
bladder  is  surrounded,  especially  at  its  base  and  around  the  seminal  vesicles 
and  lower  ends  of  the  ureters,  by  a  thick  fibro-lipomatous  mass.  (2)  Perivesical 
suppuration  and  abscess  ;  in  the  diffuse  form  the  areolar  tissue  is  widely 
infiltrated,  in  the  circumscribed  form  the  pus  is  thick  and  foul.  The  abscess 
may  rupture  into  the  bladder,  rectum,  peritoneum,  or  bowel,  and  a  recto-  or 
entero-vesical  fistula  follow. 

Symptoms.  1.  Pericystitis  from  bladder  disease. — There  is  a  greatly 
thickened  bladder  wall,  and  perhaps  an  abdominal  tumour.  When  a  diver- 
ticulum is  present  it  may  be  demonstrated  by  radiography  after  distension  of 
the  bladder  with  bismuth  emulsion. 

Localized  perivesical  suppuration  may  develop  slowly  and  escape  recog- 
nition. An  acute  abscess  may  rupture  into  the  bladder,  causing  an  acute 
cystitis.  The  temperature  is  high,  the  patient  is  seriously  ill  and  may  have 
repeated  rigors.  A  tumour  is  found  on  suprapubic  or  bimanual  palpation, 
which  may  be  mistaken  for  malignant  growth,  or  a  bogg  can  be  felt 

from  the  rectum.  The  abscess  may  rupture  into  the  rectum  or  bowel,  and 
a  recto-  or  entero-vesical  fistula  forms  with  discharge  of  fa>ces  and  gas  by  the 
urethra. 

Prevesical  abscess,  or  abscess  of  the  space  of  Retzius,  may  be  acute  or 


THE   BLADDER 

chronic.  In  acute  prevesical  abscess,  in  addition  to  the  symptoms  of 
there  are  suprapubic  pain  and  tenderness,  dullness  on  percussion, 
and  above  the  pubes  appears  a  prominent  rounded  swelling,  which  closely 
resembles  a  distended  bladder,  but  remains  unchanged  on  emptying  the 
bladder.  In  chronic  prevesical  abscess  there  are  obscure  pain  and  a  moderate 
degree   of  cystitis. 

2.  Pericystitis  from  disease  of  other  organs. — When  an  appendicular  abscess 
invades  the  pelvis  it  may  open  into  the  bladder.  There  are  signs  of  cystitis, 
and  later  the  discharge  of  a  quantity  of  fetid  pus  in  the  urine,  followed  by 
acute  cystitis,  and  a  fistula  may  form  between  the  caecum  or  appendix  and 
the  bladder.  The  urine  remains  clear  till  the  abscess  has  ruptured  into  the 
bladder,  when  it  becomes  purulent  and  fetid,  and  if  a  fistula  forms  it  con- 
tains faecal  material  and  gas  is  passed  with  the  urine.  There  is  a  hard  mass 
in  the  region  of  the  bladder,  extending  suprapubically  or  confined  to  the 
pelvis. 

Similar  symptoms  are  produced  by  pericystitis  originating  in  the  rectum, 
sigmoid  flexure,   or  small  intestine. 

There  may  be  intermittent  discharge  of  pus  with  pain  and  fever  in  the 
intervals  of  retention  of  pus,  or  continuous  discharge  of  pus  without  general 
symptoms. 

The  diagnosis  is  made  from  the  intermittent  discharge  of  large  quantities 
of  pus  in  the  urine,  and  the  absence  of  pyonephrosis.  Cystoscopy  shows  a 
patch  of  thickened  inflamed  mucous  membrane,  and  a  round  or  irregular- 
opening  may  be  seen  in  this  area. 

Treatment. — Xo  radical  treatment  for  chronic  fibro-lipomatous 
cystitis  is  possible.  In  acute  cases  the  perivesical  areolar  planes  should  be 
freely  drained.  A  prevesical  abscess  or  an  interstitial  abscess  may  be  acci- 
dentally opened  in  exploring  the  bladder  by  suprapubic  operation.  Chronic 
abscesses  are  opened  by  a  vertical  or  transverse  suprapubic  incision  and 
blunt  dissection.     Great  care  should  be  taken  not  to  open  the  peritoneum. 

FISTULA 

1.  Suprapubic  Vesical  Fistula 

The  orifice  of  the  fistula  is  usually  situated  at  the  lower  end  of  a  supra- 
pubic operation  scar.  It  is  small,  and  may  be  surrounded  by  a  collar  of 
granulation  tissue,  or  it  may  lie  at  the  bottom  of  a  depressed  scar.  When 
the  urine  is  decomposing  and  constant  cleanliness  is  not  observed  the  scar 
is  thick  and  red  and  the  surrounding  skin  inflamed  and  excoriated. 

All  the  urine  may  escape,  or  it  may  be  discharged  partly  by  the  urethra. 
The  leak  may  be  intermittent. 

Etiology.— A  permanent  fistula  may  be  intentionally  formed  by 
the  surgeon  for  incurable  urethral  obstruction  or  other  disease.  Fistula 
resulting  from  accidental  wounds  or  from  extension  of  malignant  growths 
or  tuberculous  disease  is  rare.  The  most  frequent  form  of  fistula  results 
from  the  non-healing  of  a  suprapubic  cystotomy  wound.  This  is  caused  by 
septic  cystitis,  too  long  retention  of  drainage-tubes,  adhesion  of  the  cyst- 
otomy wound  to  the  back  of  the  pubic  symphysis,  prolapse  of  a  peritonea 
sac,  spread  of  malignant  growth  or  tuberculous  infection  along  the  track, 
unrelieved  urethral  obstruction,  or  delay  in  healing  due  to  old  age  or 
extreme  debility  or  nervous  disease. 

Treatment. — Sepsis  is  energetically  treated  by  daily  washing  the 
bladder,  a  catheter  being  tied  in  the  urethra.    Should  these  measures  fail,  the 


\  ESICO-INTES1  l\  \l.   FISTULA 

track  oi  the  fistula  Bhould  be  dissected  down  to  the  bladder  wall  and  removed, 
oare  being  taken  no  I  to  open  the  peritoneal  cavity.  The  bladdei  ic  dissected 
free  from  the  pubic  symphysis,  and  the  cavitj  explored  foi  phosphatic  debris 
and  oalculi.  If  the  bladder  is  rerj  Beptic  it  will  be  wise  to  drain  it,  and  follow 
the  operation  with  constant  or  repeated  irrigation,  Anj  urethral  obstruction 
present  must  be  removed.  It  cystitis  is  nol  Bevere  the  wound  in  the  bladder 
Bhould  be  closed  i>\  a  double  row  of  catgut  Butures  and  the  prevesical  space 
drained  for  a  fen  days.    A  catheter  i^  t  i « -*  1  in  the  urethra. 

2.  Vesk  o  [ntestinai  Fis  i  1 1-\ 

Etiology.  The  fistula  maj  be  -| taneous  or  traumatic.  Spon- 
taneous fistula  may  take  origin  in  the  bladder  in  chronic  cystitis,  malignant 
growth,  or  some  other  condition  which  will  cause  perivesical  abscess.  The 
ibscess  forms  adhesions  and  ruptures  into  the  bladder  and  bowel.  Simple, 
typhoid,  tuberculous,  or  malignant  ulceration  of  the  rectum  or  intestine  may 
lead  to  the  formation  of  a  fistula. 

Pathology.  The  vesical  opening  is  mosl  frequently  high  up  on 
the  posterior  wall;  it  is  rarest  on  the  anterior  wall.  A  fistula  on  the  right 
Bide  of  the  bladder  usually  communicates  with  the  caecum  or  appendix,  and 
one  on  the  left  side  with  the  sigmoid  flexure 

The  opening  in  the  bladder  is  small  and  is  surrounded  by  an  area  of 
inflammation.  The  communication  with  the  bowel  may  be  direct.  l>ut  there 
is  usually  either  a  tortuous  track  or  an  intermediate  cavity.  The  rectum 
is  must  frequently  affected,  then  the  sigmoid  flexure,  ileum,  and  caecum,  in 
that  order.     The  coils  of  intestine  are  matted  together  in  a  dense  mass. 

Symptoms.— When  the  bladder  is  previously  healthy,  spontaneous 
cystitis  develops,  and  may  persist  for  some  weeks  before  a  fistula  is  formed. 
There  are  symptoms  of  deep-seated  suppuration.  A  history  of  rectal  or 
intestinal  disease  or  of  chronic  cystitis  can  usually  l>e  obtained.  There  is 
occasionally  evidence  of  rupture  of  an  ahseess  into  the  bladder. 

Pneumaturia  (.see  p.  788)  is  a  constant  and  characteristic  sign,  and  may 
be  the  first  intimation  that  perforation  lias  occurred.  The  passage  of  faecal 
material  in  the  urine  may  be  constant  or  intermittent,  and  varies  from  <i 
tew  brown  shreds  to  considerable  masses  of  faecal  matter.  The  urine  is  hazy 
with  mucus  and  bacteria,  and  contains  irregular  white  flakes.  The  odour 
may  be  distinctly  faecal.  Fragments  of  undigested  food  may  be  recognized. 
When  the  fistula  is  enteric  the  urine  is  yellow  with  bile.  Cystitis  is  present 
to  a  varying  degree,  and  may  lie  remarkably  slight.  Urine  is  frequently 
passed  by  the  bowel,  and  the  whole  of  it  max  lie  discharged  in  this  way, 
giving  rise  to  frequent  watery  stools. 

On  cystoscopy,  cystitis  is  found,  but  this  may  lie  slight,  and  confined 
to  the  immediate  neighbourhood  of  the  fistulous  opening.  The  opening  may 
be  hidden  by  a  fold,  but  is  usually  seen  as  a  small  round  opening  in  which 
lies  a  plug  of  faecal  matter.     It  may  be  surrounded  by  cedematous  bulla?. 

Prognosis. — The  condition  may  exist  for  many  years  (three,  four, 
twenty)  without  affecting  the  general  health.  The  dangers  are  retention 
<>f  pus  and  fatal  matter  in  an  intermediate  cavity,  peritonitis,  ascending 
pyelonephritis,  intestinal  obstruction. 

Treatment.— The  fistula  may  close  spontaneously  if  the  bladder  and 
rectum  are  washed. 

Surgical  treatment  consists  in  deflecting  the  faeces  from  the  intestinal 
orifice,  or  in  attempting  to  close  the  Jistula.  The  portion  of  bowel  may  be 
excluded  by  short  circuit  or  by  colostomy  when  the  rectum  is  involved. 


88o  THE    BLADDER 

A  rectal  fistula  may  be  attacked  through  the  rectum  or  across  the  bladder 
after  suprapubic  cystotomy.  These  methods  are  inferior  to  the  perineal 
operation.  In  fistula  originating  above  the  rectum  the  abdomen  is  opened, 
the  coils  of  intestine  separated,  the  fistulous  portion  excised,  and  the  ends 
anastomosed.     The  fistula  is  then  closed. 

3.  Vesicovaginal  Fistula 

Etiology. — Traumatic  vesico- vaginal  fistula  is  rare,  apart  from 
surgical  operation  or  parturition.  It  may  follow  operation  on  the  genital 
organs,  vaginal  drainage  of  the  bladder  for  cystitis,  or  ulceration  due  to  a 
pessary  or  to  malignant  or  tuberculous  disease. 

Pathology. — The  common  form  opens  directly  from  the  bladder 
into  the  anterior  fornix,  less  frequently  into  the  cervix  uteri.  The  ureter 
may  be  implicated  and  a  vesico-utero-vaginal  fistula  result.  There  is  usually 
extensive  scarring  and  prolapse  of  the  vesical  mucous  membrane. 

The  vagina,  vulva,  and  skin  of  the  thighs  are  irritated  and  excoriated  by 
the  escaping  urine.     There  is  cystitis,  and  sometimes  vesical  calculus. 

Symptoms  and  diagnosis.— The  vaginal  escape  of  alkaline  and 
decomposing  urine  is  the  chief  symptom.  In  vesico-uterine  fistula  the  urine 
is  seen  to  issue  from  the  os  uteri,  and  coloured  fluid  injected  into  the  bladder 
appears  at  the  os. 

In  vesico-utero-vaginal  fistula  the  discovery  of  the  ureteric  orifice  is 
assisted  by  the  intramuscular  injection  of  methylene  blue  or  indigo  carmine. 

Treatment. — Before  undertaking  a  plastic  operation  the  urine  must 
be  rendered  aseptic,  calculi  removed,  and  vulvo-vaginitis  treated.  Suprapubic 
cystotomy  should  be  established  for  at  least  a  week  before  the  operation. 
There  are  three  methods  of  approach — (1)  vaginal,  (2)  vesical,  (3)  peritoneal. 
The  vesical  and  vaginal  should  be  combined.  Various  plastic  operations 
have  been  practised.  For  a  week  after  the  operation  the  bladder  is  kept 
dry  by  means  of  a  White's  suction  apparatus. 

NERVOUS   DISEASES 

The  nervous  diseases  which  affect  the  bladder  are  principally  spinal 
lesions.  Cerebral  disease  seldom  affects  the  organ  so  long  as  consciousness  is 
retained,  and  it  is  doubtful  if  it  is  influenced  by  changes  in  the  peripheral 
nerves.    Nervous  disease  of  the  bladder  gives  rise  to  the  following  symptoms  : — 

1.  Pain. — There  may  be  either  constant  aching  in  the  bladder,  un- 
affected by  micturition,  or  attacks  of  acute  pain  (vesical  crises). 

2.  Increased  desire  and  bladder  spasm. — This  may  be  the  only  symptom 
or  may  be  one  symptom  in  a  group.  It  is  not  infrequently  combined  with 
partial  retention.     Spasm  of  the  bladder  may  lead  to  active  incontinence. 

3.  Absence  of  desire  may  result  in  the  patient  passing  water  only  once  or 
twice  in  the  twenty-four  hours.  With  this  there  is  residual  urine  in  varying 
amount.     There  is  diminished  sensibility  of  the  bladder. 

4.  Difficult  micturition. — This  is  present  in  almost  all  cases  of  nervous 
disease  of  the  bladder  in  spinal  lesions,  and  is  combined  with  residual  urine. 
There  are  delay  in  commencing  micturition,  a  feeble  stream,  straining,  and 
dribbling. 

5.  Complete  retention  of  urine  is  due  to  paralysis  of  the  bladder  muscle. 
This  may  be  present  at  the  onset  of  the  bladder  affection,  and  the  tone  of 
the  muscle  improves  later,  so  that  micturition  can  be  performed,  but  the 
bladder  is  incompletely  emptied. 

6.  Incontinence  of  urine  (see  p.  848). 


NERVOUS   AFFECTIONS   AND  THE    BLADDER      881 

The  following  varieties  of  nervous  affections  of  the  bladder 
are  observed  : 

I.  Activi  incontinence,  (o)  Reflex  micturition.  (6)  Incomplete  reflex 
mirt  urition. 

•_'.  PaaaiiM  incontinence,  (a)  Distension  with  overflow.  (6)  Collapse  with 
outflow. 

When  the  bladder  is  oul  off  from  the  control  of  the  oerebrum  it  acts 
automatically.      A  quantity  of  mine  collects,   the  reflex  of  micturition  is 

initiated,  and  the  bladder  empties  it  sell.  Tins  is  repeated  at  intervals  ("flush- 
ing tank  action  ").  The  condition  OCOUTS  in  lesions  above  the  lumbar  centre, 
and.  as  Miillei'  has  shown,  in  lesions  involving  the  lumbar  centre  also.  There 
is  sometimes  uncontrollable  spasm  of  the  bladder. 

The  bladder  may  he  fully  or  partly  distended,  and  the  urine  is  passed 
involuntarily  by  bladder  contraction  from  time  to  time  In  passive  incon- 
tinence the  contraction  of  the  bladder  is  abolished  and  the  outflow  is  purely 
mechanical.  The  bladder  may  be  fully  distended  or  it  may  be  collapsed, 
hut  it  is  seldom,  if  ever,  completely  empty,  a  certain  amount  of  urine  collecting 
before  the  elastic  resistance  of  the  urethra  is  overcome. 

Changes  in  the  bladder  in  nervous  diseases.— Cystitis 
is  frequently  present,  the  infection  being  usually  introduced  by  the  catheter. 
The  cystitis  becomes  chronic,  and  the  urine  is  frequently  alkaline  and 
ammoniacal.  Phosphatic  calculi  form  rapidly.  Trabeculation  of  the  bladder 
is  observed  in  tabes  dorsalis,  and  I  have  found  it  also  in  atony  from 
posterolateral  sclerosis  and  from  spina  bifida,  but  it  was  absent  in  cases 
of  multiple  sclerosis  and  supralumbar  myelitis.  It  also  occurs  in  idiopathic 
atony  of  the  bladder.  In  my  opinion,  the  trabeculation  in  these  cases  is  due 
to  atrophy  and  not  to  hypertrophy  of  the  bladder  muscle. 

Rarely,  in  spinal  disease,  ulceration  of  the  bladder  may  develop  and 
rapidly  perforate. 

Bladder  symptoms  in  special  nervous  diseases.— The 
bladder  is  more  frequently  affected  in  tabes  than  in  other  forms  of  nervous 
disease,  and  the  vesical  symptoms  may  appear  when  the  symptoms  of  spinal 
disease  are  only  partly  developed.  There  is  gradually  increasing  difficulty 
in  micturition — delay  in  commencing,  loss  of  power  of  projection,  intermittent 
flow,  and  after-dribbling;  there  may  be  a  diminished  desire.  A  varying 
quantity  of  residual  urine  is  found,  and  there  is  widespread  trabecula- 
tion. The  atony  increases  until  there  is  complete  retention,  or  this  may 
rapidly  develop  at  the  commencement  of  the  bladder  symptoms.  Nocturnal 
enuresis  is  usually  present.  After  a  varying  period  of  weeks  or  months  the 
tone  of  the  bladder  frequently  improves,  so  that  there  are  8  or  10  oz.  of 
residual  urine,  and  the  rest  is  passed  voluntarily.  Vesical  and  urethral  crises  are 
rare.  In  acute  and  chronic  spinal  meningitis  and  acute  and  chronic  myelitis, 
and  in  multiple  sclerosis,  the  characteristic  change  is  gradually  increasing 
atony  of  the  bladder,  and  eventually  complete  retention  develops,  and  drib- 
bling of  urine  from  overflow  follows.  This  may  continue,  but  usually  the 
bladder  acts  automatically  after  a  tune.  Spasmodic  contraction  of  the 
bladder  is  occasionally  observed,  but  this  later  passes  into  the  atonic  con- 
dition described.  In  spina  bifida  affecting  the  sacral  canal,  atony  of  the 
bladder  may  be  observed. 

Atony  of  the  bladder  without  obstruction  or  signs 
of  nervous  disease. — I  have  described  a  series  of  cases  under  this 
title.  The  condition  occurs  in  young  and  middle-aged  patients,  and  is 
unconnected  with  venereal  disease.    There  is  gradual  onset  of  difficulty  in 

3* 


882  THE    URETHRA 

micturition,  delay,  feeble  and  intermittent  stream.  Chronic  distension  of 
the  bladder  with  voluntary  micturition  may  be  present,  or  residual  urine 
amounting  to  4  to  10  oz.  There  is  loss  of  sensibility  of  the  bladder  in  some 
cases  and  increased  sensibility  in  others.  Well-marked  trabeculation  (atrophy) 
of  the  bladder  is  present  in  all. 

Urethral  obstruction  and  spinal  disease  are  eliminated. 

The  disease  was  present  in  cases  for  eight  to  eighteen  years  without  the 
development  of  nervous  lesions.  The  lesion  is  probably  localized  in  the 
hypogastric  and  hsemorrhoidal  plexuses  of  the  sympathetic. 

Injury  to  the  nervous  system. — Corner  gives  the  following 
table  of  the  state  of  the  bladder  in  various  injuries: — 

Concussion  of  the  brain. 

1.  Reflex  or  unconscious  micturition. 

2.  Active    retention :  (a)    active    overflow ;     (6)    passive    overflow  ; 

(c)  absolute  retention. 
Compression. 

1.  Passive  retention. 

2.  Active  paralytic  overflow. 

3.  Passive  paralytic  overflow. 
Spinal  injuries. 

1.  Supralumbar  lesions :  (a)  active  retention  ;    (b)  reflex  micturition  ; 

(c)  exaggerated  reflex  micturition. 

2.  Lumbar  lesions :  (a)  passive  retention ;  (b)  active  paralytic  over- 

flow ;  (c)  passive  overflow. 

Treatment.  I.  Relief  of  retention  and  removal  of  re- 
sidual urine. — Rigid  asepsis  must  be  observed.  For  complete  retention 
the  catheter  must  be  passed  thrice  in  twenty-four  hours.  The  tone  of  the 
bladder  frequently  improves  with  regular  catheterization,  and  the  frequency 
of  catheterization  may  be  reduced.  When  the  residual  urine  does  not  exceed 
6  or  10  oz.,  the  catheter  should  be  passed  once  a  day,  and  if  less  than  that, 
once  a  week.     If  urethral  obstruction  is  present  it  must  be  removed. 

2.  Prevention  and  treatment  of  cystitis.— Urinary  antiseptics 
should  be  given  from  the  commencement  of  the  bladder  symptoms,  and 
constipation  prevented.  If  infection  has  occurred  the  bladder  is  washed 
out  (see  under  Cystitis,  p.  862).  The  bladder  should  be  examined  from  time 
to  time  to  ascertain  if  a  phosphatic  calculus  has  formed. 

3.  Treatment  of  atony. — The  patient  should  be  encouraged  to 
try  to  expel  all  the  urine,  he  should  be  regularly  catheterized,  and  should 
be  given  ergot  (liquid  extract,  20-30  minims  thrice  daily)  and  strychnine 
(liquor,  5  minims).  Mercury  and  iodides  have  no  effect.  The  electrical 
current  may  be  used  with  advantage,  one  terminal  being  placed  over  the 
suprapubic  region  or  the  sacrum  and  the  other  over  the  perineum,  or  an 
electrode  may  be  introduced  into  the  bladder  or  into  the  rectum.  A  weak 
interrupted  current  should  be  used,  and  at  first  the  sittings  are  short.  The 
galvanic  current  may  also  be  employed. 

THE    URETHRA 

Anatomy  (Figs.  202,  203,  Vol.  I.,  pp.  806,  807). — The  male  urethra 
is  divided  anatomically  into  three  parts — the  prostatic  (1|  in.),  the  mem- 
branous (§  in.),  and  the  spongy  urethra  (about  6  in.) ;  a  pars  intramurales 
is  also  described. 

Clinically,   the  canal   is  more  conveniently  divided  by   the  compressor 


ANATOMY    OV   TIIK    UKKTHRA  883 

urethra)  muscle  into  the  posterior  urethra  (corresponding  to  the  prostatic 
mcthra)  and  the  anterior  urethra,  which,  again,  is  divided  into  the  bulbous 
or  perineal  and  the  penile  urethra. 

The  urethra  has  an  S -shaped  curve.  The  internal  meatus  is  situated  on 
a  level  with  the  middle  of  the  pubic  symphysis  and  about  _'  om.  behind  it. 
Thence  the  canal  passes  vertically  downwards  for  about  A  to  \  in.  to  the 
level  oi  the  verumontanum  ;  there  it  turns  slightly  forwards  and  maintains 
a  forward  and  downward  direction  to  the  junction  of  the  membranous  and 
bulbous  urethra.  The  canal  now  turns  sharply  upwards  and  forwards  along 
the  under  surface  of  the  triangular  ligament.  At  the  peno-scrotal  junction 
it  turns  downwards  in  the  flaccid  penis  to  the  meatus.  The  fixed  curve 
of  the  urethra  extends  from  the  peno-scrotal  junction  to  the  internal  meatus, 
the  deepest  part  of  the  curve  lying  at  the  termination  of  the  bulbous  urethra, 
the  cul-de-sac  du  bidbe.  This  is  4  cm.  from  the  internal  meatus  and  3  cm. 
from  the  peno-scrotal  junction.  The  angle  formed  by  these  two  segments 
is  one  of  93  degrees.  The  walls  of  the  urethra  lie  in  contact.  Its  calibre 
and  musculature  are  described  elsewhere  (Vol.  I.,  p.  805).  The  lining 
epithelium  is  columnar,  except  at  the  fossa  navicularis,  where  it  is  squamous. 

On  the  posterior  wall  of  the  prostatic  urethra  is  the  verumontanum,  on 
which  the  sinus  pocularis  and  ejaculatory  ducts  open.  On  each  side  of  this 
ridge  is  a  gutter-like  prostatic  sinus,  into  which  the  prostatic  ducts  open. 

The  membranous  urethra,  which  is  surrounded  by  the  compressor  urethrae 
muscle,  has  numerous  mucous  glands.  On  each  side  of  this  lie  Cowper's 
glands.  In  the  mucous  membrane  of  the  anterior  urethra  there  are  mucous 
glands  (glands  of  Littre),  the  ducts  of  which  open  obliquely  forward.  There 
are  also  10  or  12  larger  lacuna?  on  the  roof,  and  the  largest  of  these  (lacuna 
magna)  opens  on  the  roof  of  the  fossa  navicularis.  The  ducts  of  Cowper's 
glands  open  on  the  floor  of  the  bulbous  urethra,  1  in.  in  front  of  the  mem- 
branous urethra.  The  lymphatics  of  the  prostatic  urethra  pass  to  the  glands 
along  the  internal  iliac  vessels,  those  of  the  membranous  and  bulbous  urethra 
to  the  glands  along  the  external  iliac  vessels  and  internal  pudic  vessels,  those 
of  the  spongy  urethra  to  the  inguinal  and  femoral  glands. 

Female  Urethra. — The  female  urethra  is  1£  in.  long,  has  a  slight 
anterior  concavity,  and  is  intimately  united  with  the  anterior  vaginal  wall. 
The  external  meatus  is  the  narrowest  part.  The  epithelium  is  squamous  at 
the  external  end  and  columnar  near  the  bladder. 

Examination. — On  rectal  examination  the  membranous  urethra  can 
be  felt  in  the  middle  line  below  the  prostate,  and  the  prostatic  urethra  lies 
in  the  vertical  sulcus  between  the  lobes  of  the  prostate. 

For  examination  of  the  urethra  with  sounds,  an  acorn-tipped  bougie  or 
bougie  a  bovle  is  used.  If  it  is  arrested,  the  distance  from  the  external 
meatus  is  noted  and  a  smaller  instrument  is  tried.  There  may  be  creaking 
on  passing  through  a  cartilaginous  stricture,  grating  in  passing  over  a  stone 
or  a  phosphatic  deposit,  or  a  tearing  sensation  when  a  false  passage  is  made, 
Resistance  is  felt  o\  or  6  in.  from  the  meatus  at  the  contracted  membranous 
urethra ;  this  is  overcome  by  gentle  pressure  on  the  perineum.  There  is 
slight  resistance  at  the  entrance  of  the  bladder. 

Urethroscopy. — There  are  two  varieties  of  urethroscope.  In  one 
the  light  is  reflected  from  a  lamp  at  the  proximal  end  of  the  tube,  and  in 
the  other  the  lamp  is  placed  in  the  lumen  of  the  tube  at  its  distal  end.  For 
the  anterior  urethra  the  tube  is  5£  in.  long,  and  straight,  being  provided 
with  a  metal  obturator.  For  the  posterior  urethra  the  tube  is  8k  in.  long, 
and  has  a  curved  beak,  the  distal  opening  being  on  the  convexity  of  the  beak. 


SS4  THE   URETHRA 

For  anterior  urethroscopy  the  patient  lies  on  a  high  table,  and  the  tube 
with  the  obturator  in  position  is  oiled  and  introduced.  The  instrument  sinks 
as  far  as  the  membranous  opening,  the  obturator  is  removed,  and  a  pledget 
of  cotton-wool  on  a  carrier  introduced  to  remove  the  moisture.  The  lantern 
is  applied  to  the  tube  and  the  light  switched  on.  The  urethra  is  examined 
as  the  tube  is  slowly  withdrawn.  The  tap  of  the  air-bulb,  which  has  pre- 
viously been  distended,  is  now  opened,  and  the  urethra  distends  like  a  tunnel. 
Air- distension  is  especially  useful  in  examining  a  stricture. 

For  examination  of  the  prostatic  urethra  the  pelvis  of  the  patient  is  raised 
on  a  cushion,  or  the  patient  is  placed  in  a  special  chair  with  the  hips  and 
knees  well  flexed. 

The  posterior  urethra  is  anaesthetized  by  introducing  20  minims  of  a 
1  per  cent,  cocaine  solution  by  means  of  a  Guyon's  syringe.  The  posterior 
urethroscope  tube  is  well  depressed  when  the  beak  reaches  the  membranous 
urethra,  so  that  it  passes  on  into  the  prostatic  portion.  The  obturator  is 
withdrawn,  a  tampon  of  wool  introduced  to  remove  the  moisture,  and  the 
lantern  is  applied. 

The  female  urethra  can  be  palpated  on  the  anterior  wall  of  the  vagina. 
The  urethroscope  is  used  in  the  same  manner  as  in  the  male,  but  without 
air-distension. 

Urethral  shock. — On  the  first  instrumentation  a  nervous  patient 
may  feel  faint,  but  quickly  recovers  on  the  application  of  the  usual  remedies. 
True  urethral  shock  is  rare,  and  is  a  much  more  serious  condition.  During 
or  immediately  after  the  passage  of  an  instrument  the  patient  gives  a  few 
short  gasps,  becomes  unconscious,  and  after  one  or  two  inspiratory  stridors 
stops  breathing.  The  pupils  dilate,  the  pulse  becomes  imperceptible,  and 
the  heart  sounds  cease.  A  loud  expiratory  effort  may  occur  after  breathing 
has  stopped.  The  condition  is  fatal  in  a  large  proportion  of  cases.  Energetic 
stimulation  and  artificial  respiration  may  be  tried,  and  are  occasionally 
successful. 

URETHRAL,   URINARY,   OR   CATHETER   FEVER 

The  rise  of  temperature  that  sometimes  follows  instrumentation  has  been 
ascribed  on  one  theory  to  nervous  influences,  and  on  another  to  sepsis.  It 
is  now  generally  accepted  that  urethral  fever  is  septic  in  origin,  the  infection 
uriL'inating  either  in  a  septic  instrument,  in  an  ahead}*  infected  urethra,  or 
in  septic  urine.  Infection  is  more  likely  to  take  place  when  an  obstructive 
lesion  is  present  than  in  an  unobstructed  urethra,  in  lesions  of  the  bulbous 
than  of  the  penile  urethra,  and  in  those  of  the  prostatic  than  of  the  anterior 
urethra.  A  rough  inexperienced  hand  is  more  likely  to  produce  urinary 
fever  than  a  gentle  educated  touch. 

Types    of    urethral    fever.    1.  Urethral    fever    without 

Suppression     of    urine.— («)    The    temperature    may    rise    to    100°  F. 
or  101°  F.,  with  slight  malaise,  but  falls  again  in  a  few  hours  to  normal. 

(6)  A  single  severe  rise  to  102°  F.,  or  higher,  accompanied  by  a  rigor, 
may  occur  a  few  hours  after  the  passage  of  an  instrument.  The  patient 
is  restless  and  ill.  the  tongue  dry,  the  mouth  parched,  the  urine  scanty  and 
high-coloured.  In  twenty-four  to  thirty-six  hours,  after  profuse  perspira- 
tion, the  temperature  falls  to  normal. 

(c)  The  fever  is  prolonged  (acute  remittent  type).  After  an  initial  rigor 
the  temperature  rises  to  102°  F.  or  higher,  remaining  high  for  several  days, 
then  falling  gradually  to  normal,  sometimes  with  a  short  recurrent  rise. 

(d)  A  rigor  follows  internal   urethrotomy,  and  the  temperature  rises  to 


URETHRAL   FEVER  885 

lo.V  F.  or  10-4°  F..  and  falls  in  a  few  hours.  A  second  rigor  occurs  with  another 
rise  of  temperature,  and  the  rigors  are  repeated  at  irregular  intervals.  Venous 
thrombosis,  pneumonia,  or  other  complications  eventually  supervene,   and 

the   patient    dies  after  several   weeks. 

2.  Urethral  fever  with  suppression  of  urine.— (a)  There 
is  a  rigor  a  few  hours  after  internal  urethrotomy,  and  the  temperature  rises 
to  104°  P.,  or  even  higher.  A  few  ounces  of  bloody  urine  are  passed,  and  the 
Secretion  becomes  completely  suppressed.  The  patient  is  restless  and  wanders. 
He  becomes  rapidly  comatose,  and  dies  within  eighteen  to  thirty-six  hours 
of  the  operation. 

(b)  After  the  passage  of  a  catheter  in  a  case  of  enlarged  prostate  there 
is  a  rise  of  temperature,  and  the  tongue  is  dry  and  glazed.  The  patient  is 
drowsy  and  heavy,  and  wanders  at  night.  The  temperature  remains  high; 
buccal  dysphagia,  hiccup,  and  vomiting  follow ;  the  quantity  of  urine 
diminishes  and  complete  suppression  supervenes,  and  death  results  in  a 
considerable  proportion  of  cases. 

Treatment. — Prophylactic  treatment  consists  in  the  sterilization  of 
all  urethral  instruments,  washing  the  bladder  and  urethra  with  nitrate  of 
silver  when  the  urine  is  already  septic,  and  the  administration  of  urinary 
antiseptics  and  diuretics  before  and  after  instrumentation.  When  infection 
has  occurred  a  smart  purge  is  administered,  diuretics  such  as  Contrexeville 
water  or  barley-water  are  freely  given,  and  urinary  antiseptics  administered. 
If  the  infection  is  due  to  the  Bacillus  coli,  large  doses  of  alkalis  should  be 
given.  A  catheter  is  tied  in  the  urethra,  and  in  some  cases  suprapubic  drainage 
is  installed.     Vaccine  and  serum  treatment  may  be  tried. 

The  treatment  of  suppression  of  urine  is  discussed  elsewhere  (p.  783). 

CONGENITAL    MALFORMATIONS 

Congenital  Absence  or  Obliteration  op  the  Urethra 
This  is  rare.    The  penis  is  absent  or  rudimentary,  and  other  malformations 
are  present.     The  bladder  may  communicate  with  the  rectum,  uterus,  or 
umbilicus.     The  children  are  usually  still-born  or  die  soon  after  birth. 

Partial  Obliteration  of  the  Urethra 
This  may  be  found  in  the  glans,  in  the  bulbous,  membranous,  or  prostatic 
urethra.     The  anterior  urethra  is  most  commonly  and  the  prostatic  urethra 
least  often  affected. 

If  no  outlet  is  present,  there  is  distension  of  the  bladder  with  dilatation 
of  the  ureters  and  kidneys.  The  kidneys  may  be  the  seat  of  congenital 
malformation  and  be  inactive,  so  that  distension  of  the  urinary  passages 
does  not  take  place.  The  urine  may  find  an  outlet  through  a  patent  urachus, 
a  vesico-rectal  fistula,  a  vesico-utero-rectal  fistula,  a  penile  or  vaginal  fistula. 
In  the  majority  of  cases  the  child  is  still-born  or  dies  soon  after  birth.  If 
life  is  prolonged,  fatal  ascending  infection  occurs  after  a  few  years. 

Treatment. — Suprapubic  puncture  and  cystotomy  are  emergency 
operations  to  relieve  distension.  In  atresia  of  the  glans  uretlme  the  dilated 
urethra  should  be  opened  and  a  penile  fistula  established,  a  plastic  operation 
being  carried  out  later  on  the  urethra. 

Double  Urethra 
This  is  rare,  and  may  be  combined  with  double  penis,  double  scrotum, 
double  bladder,  atresia  ani,  and  other  congenital  malformations. 


886  THE    URETHRA 

The  second  urethra  may  open  on  the  perineum  or  in  the  inguinal  region. 
A  more  frequent  condition  is  where  a  canal  opens  on  the  glana  or  below  the 
penis  and  runs  backwards  on  the  upper  or  under  surface  of  the  penis.  The 
track  varies  in  length  from  J  to  5£  in.,  and  usually  ends  blindly.  In  a  few 
cases  the  canal  joins  the  urethra,  and  rarely  it  passes  back  into  the  bladder. 

A  double  urethra  has  been  described  in  the  female  subject. 

When  the  second  canal  communicates  with  the  urethra  or  bladder,  urine 
escapes  from  both  orifices.  The  penis  may  swing  from  side  to  side  during 
micturition.  In  gonorrhceal  infection  there  is  discharge  from  both  orifices, 
but  the  infection  may  attack  the  abnormal  canal  while  the  urethra  escapes. 
When  the  abnormal  canal  is  the  seat  of  chronic  inflammation  it  may  be  laid 
open  in  its  entire  length  and  the  lining  membrane  destroyed  with  the  cautery. 
A  thick  scar  may  result  which  interferes  with  erection.  Extirpation  of  the 
unopened  tract  by  dissection  is  more  difficult,  but  the  after-result  is  better. 

Congenital  Narrowing  of  the  Urethra 
The  points  most  frequently  affected  are  the  external  meatus,  the  junction 
of  the  fossa  navicularis  and  the  penile  urethra,  the  membranous  urethra,  and 
the  prostatic  urethra.     The  external  meatus  is  most  frequently  the  seat  of 
stenosis.     The  symptoms  are  those  of  stricture. 

Treatment. — In  stenosis  of  the  meatus  the  urethra  is  slit  down- 
wards, and  the  mucous  membrane  and  skin  are  brought  together  by  catgut 
sutures.  In  deeply  situated  stenosis,  dilatation  with  graduated  bougies 
should  be  tried,  and,  that  failing,  external  urethrotomy,  followed  by  the 
regular  instrumentation. 

Congenital  Dilatation  of  the  Urethra 
This  is  independent  of  stenosis.  The  dilatation  affects  the  under  surface 
of  the  penile  urethra,  rarely  the  bulbous  urethra.  A  similar  condition  may 
occur  in  the  female  urethra.  Symptoms  may  appear  soon  after  birth,  or  may 
be  delayed.  Micturition  is  frequent  and  painful,  the  stream  is  poor  and  is 
followed  by  dribbling.  A  swelling  appears  on  the  under  surface  of  the  penis 
during  micturition,  and  the  penis  may  be  twisted  to  one  or  other  side,  or 
becomes  erect.     Incontinence  is  a  late  result. 

Treatment. — The  sac  should  be  excised,  the  urethra  repaired,  and 
the  skin  stitched  separately.     A  catheter  is  tied  in  after  the  operation. 

Hypospadias    and   Epispadias 
These  conditions  are  considered  at  pp.  966,  967. 

PROLAPSE 

About  170  cases  of  this  rare  condition  are  on  record,  more  than  half  of 
them  in  girls  under  15,  and  most  of  the  rest  in  elderly  women.    (See  p.  985.) 

URETHROCELE 

This  condition — a  pouching  of  the  urethral  mucous  membrane,  filled  with 
decomposing  purulent  urine — is  considered  at  p.  985.  A  similar  condition 
may  occur  in  men. 

INJURIES   AND    RUPTURE 

Injuries 
The  urethra  may  be  injured  from  within  the  lumen  by  the  passage 
of   instruments  (see   p.  883),  or    from  without  by  cutting  weapons, 


IKl.'l  IIKAL    IU  I'll   Kl  887 

bullets,  etc,  The  penile  urethra  \a  mosl  frequently  affected.  Kaemor- 
1-  usually  severe.  When  free  exit  for  the  urine  1-  afforded  qo 
extravasation  takes  place,  bul  when  the  urethral  wound  does  nor 
correspond  to  the  skin  wound,  01  when  the  wound  is  in  the  perineum, 
widespread  extra vasation  is  likely  t<>  occur.  Immediate  exploration 
and  suture  of  the  urethra  should  be  carried  out,  and  a  catheter  tied 
in  the  urethra  foi  four  days.  When  suppuration  and  extrava 
have  already  taken  place,  a  catheter  should  l>e  tied  in  and  the  wound 
t horoughly  cleansed. 

Rupture 

There  may  be  bruising  of  the  mucous  membrane  (interstitial  rup- 
ture), rupture  of  the  fibrous  sheath  (partial  external  rupture),  of  the 
mucous  membrane  (partial  internal  rupture),  or  of  the  mucous  mem- 
brane, corpus  spongiosum,  and  fibrous  sheath  (total  rupture).  A 
pair  of  the  circumference  of  the  urethra  (partial  rupture)  or  the  whole 
circumference  (complete  rupture)  may  be  affected.  In  complete  rup- 
ture the  severed  ends  retract  and  may  be  widely  separated. 

Eupture  of  the  penile  urethra  is  rare,  and  results  from  injuries 
during  erection.     The  seat  of  election  is  the  peno-scrotal    junction. 

Rupture  of  the  bulbous  urethra  is  more  frequent,  and  results  from 
a  kick,  or  blow,  or  fall  on  the  perineum.  The  rupture  is  usually  com- 
plete and  total,  and  the  severed  ends  retract  some  distance.  The 
position  of  the  rupture  depends  upon  the  attitude  of  the  body  at  the 
time  of  the  injury.  A  force  striking  the  perineum  from  before  back- 
wards injures  the  bulbous  urethra,  but  one  striking  the  perineum 
from  behind  forwards  damages  the  membranous  urethra.  The 
urethra  is  crushed  between  the  injuring  body  and  the  pubic  arch  and 
triangular  ligament.  Rupture  of  the  membranous  urethra  occurs  in 
severe  injuries  with  fracture  of  the  pelvis  or  dislocation  of  the  pubic 
bones.     The  prostatic  urethra  is  rarely  ruptured. 

Symptoms. — In  penile  rupture  there  is  haemorrhage  from  the 
meatus  for  a  few  days,  pain  on  micturition,  but  rarely  retention  of 
urine.  Extravasation  of  urine  does  not  occur,  but  stricture  invari- 
ably follows.  Rupture  of  the  bulbous  urethra  is  the  most  common 
form.  After  a  blow  on  the  perineum  there  is  sharp  pain,  increasing 
in  severity,  and  blocd  appears  at  the  meatus.  A  tumour  rapidly  forms 
in  the  perineum,  which  becomes  tense  and  tender.  In  slight  cases 
where  the  fibrous  sheath  is  not  ruptured  this  swelling  is  absent. 
Retention  of  urine  frequently  follows  the  injury.  Membranous  or 
prostatic  rupture  is  associated  with  fracture  of  the  pelvis,  and  may 
escape  observation  at  first.  Haemorrhage  is  slight,  and  bruising 
appears  in  the  perineum  after  some  days.  There  is  retention  of  urine. 
A  tender  swelling  is  felt  on  rectal  examination,  and  the  abdominal 
muscles  are  frequently  rigid.     The  bladder  is  distended. 


888  THE   URETHRA 

Diagnosis. — The  history  and  symptoms  are  usually  sufficient 
to  make  the  diagnosis  easy.  Differentiation  between  rupture  of  the 
posterior  urethra  and  extraperitoneal  rupture  of  the  bladder  is  dif- 
iicult.  In  the  former,  tenderness  and  swelling  are  present  around  the 
membranous  and  prostatic  urethra  on  rectal  examination,  and  on 
passing  a  catheter  there  is  obstruction  at  the  posterior  urethra.  The 
bladder  is  distended  in  rupture  of  the  urethra. 

Prognosis. — In  penile  rupture  the  symptoms  rapidly  subside, 
but  a  stricture  forms  within  a  few  months.  In  bulbous  rupture  extra- 
vasation and  infection  follow  the  attempted  passage  of  urine,  and 
the  patient  may  succumb  if  operation  is  delayed.  In  less  severe  cases 
the  hsematoma  breaks  down  and  fistulee  form  in  the  perineum.  Stric- 
ture usually  follows  in  a  few  weeks,  but  may  be  delayed  for  some  years. 

Treatment.  —  In  rupture  of  the  penile  urethra  the  canal  is 
washed  with  silver-nitrate  solution  (1  in  10,000)  and  a  soft  catheter  is 
tied  in  for  four  days.  Metal  instruments  are  passed  after  a  fortnight, 
and  this  is  continued  regularly.  In  bulbous  rupture  a  metal  catheter 
is  passed  gently  along  the  urethra,  keeping  to  the  roof.  If  it  enters 
the  bladder  the  urine  is  drawn  off  and  the  instrument  kept  in  posi- 
tion. If  it  does  not  pass  the  rupture  it  is  left  in  the  urethra.  The 
patient  is  placed  in  the  lithotomy  position  and  the  hseniatoma  incised. 
A  curved  transverse  incision  is  preferable  for  membranous  rupture, 
and  a  median  incision  for  bulbous.  The  clots  are  turned  out  and  the 
oozing  stopped  by  irrigation  with  hot  lotion.  If  the  urethra  is  only 
partly  severed  the  torn  edges  are  readily  found  and  are  trimmed  and 
sutured  with  catgut  over  a  catheter  which  is  tied  in  position.  If 
the  urethra  is  completely  severed  the  vesical  end  is  difficult  to  find. 
The  two  ends  are  united  with  catgut  and  the  perineum  repaired.  If 
the  ends  cannot  be  approximated  the  cavity  is  lightly  packed  and 
drained  and  a  catheter  fixed  in  place.  Suprapubic  drainage  should 
be  established  and  continued  for  a  fortnight.  Should  the  vesical  end 
not  be  found,  suprapubic  cystotomy  must  be  performed  and  the  end 
identified  after  retrograde  catheterization. 

Results. — The  mortality  of  uncomplicated  rupture  of  the  urethra 
was  14-15  per  cent,  in  205  cases  (Kaufmann).  Treatment  by  retained  catheter 
has  a  mortality  of  18-17  per  cent.,  and  rupture  of  the  urethra  with  fracture 
of  the  pelvis  a  mortality  of  40  per  cent. 

In  a  large  number  of  cases,  immediate  operation  has  prevented  the 
formation  of  stricture  or  reduced  the  contraction  to  a  linear  scar  readily 
amenable  to  treatment. 

CALCULUS 

There  are  two  varieties  of  this  condition — (1)  primary,  when  the 
stone  originates  in  the  urethra  ;  (2)  secondary,  when  a  migrating  cal- 
culus is  arrested  in  the  canal. 

Etiology. — Primary  calculi  originate  in  phosphatic  crusts  that 


URETHRAL   CALCULUS  889 

are  deposited  on  raw  Burfacea  in  the  urethra,  especially  when  stricture 

is  present,  or  iii  a  para-urethra]  pocket. 

Pathology.  Primarj  urethra]  calculi  are  composed  of  calcium  and 
magnesium  phosphate,  ammonio-magnesium  phosphate,  or  calcium  carbonate. 
Secondary  calculi  have  a  nucleus  of  uric  acid,  oalcium  oxalate,  or othei  ingre- 
dients found  in  renal  or  vesical  calculi.  As  the  calculus  grows  it  is  moulded 
by  the  shape  of  the  urethra,  and  the  urethra  itself  becomes  dilated.  Several 
faceted  calculi  may  be  found.  When  a  urethral  calculus  projects  into  the 
I 'ladder  it  takes  a  mushroom  or  umbrella  shape.  In  the  majority  of  cases 
one  or  several  strictures  coexist,  and  the  calculus  lies  behind  a  stricture  or 
between  two  strictures.  Perineal  fistula.-  may  be  present.  A  calculus  may 
lie  in  a  pouch  communicating  with  the  urethra,  and  project  into  the  canal. 

Symptoms.  1.  Impaction  of  a  migrating  stone. — There  is 
frequently  a  preliminary  attack  of  renal  colic,  when  the  stone  descends 
from  the  kidney.  The  stone  is  felt  to  enter  the  urethra  during  mic- 
turition, and  there  is  sudden  arrest  of  the  stream,  intense  pain,  and 
continuous  ineffectual  straining,  with  the  passage  of  a  few  drops  of 
blood,  followed  by  complete  retention  of  urine.  On  passing  a  metal 
catheter  the  membranous  urethra  is  found  spasmodically  contracted, 
and  the  click  of  a  stone  is  felt  in  the  prostatic  urethra.  The  calculus 
may  be  felt  from  the  rectum.  Recurrent  attacks  of  difficult  micturi- 
tion or  complete  retention  occur  when  the  stone  becomes  impacted 
behind  a  stricture  of  the  bulbous  or  penile  urethra,  and  the  calculus 
can  be  felt  on  palpating  the  urethra. 

2.  Stone  lodged  in  the  urethra. — There  are  pyuria  and  a 
urethral  discharge,  difficult  and  frequent  micturition,  discomfort,  and 
a  feeble,  twisted  stream.  Urinary  fistulse  may  be  present,  and  there 
is  usually  a  stricture.  The  stone  is  felt  on  palpation  and  seen  on 
urethroscopic  examination. 

Treatment. — A  migrating  calculus  of  the  prostatic  urethra  is 
usually  pushed  back  into  the  bladder  on  passing  a  catheter.  It 
should  be  evacuated  with  a  lithotrity  bulb  or  crushed  and  removed. 
If  the  calculus  is  not  pushed  back  into  the  bladder  the  catheter  may 
be  tied  in  position  for  a  few  days  ;  on  its  being  removed  the  stone  will 
probably  be  expelled. 

Small  calculi  in  the  penile  and  bulbous  urethra  can  sometimes 
be  removed  with  urethral  forceps  or  a  snare  if  no  stricture  is  present. 
If  they  lie  behind  a  stricture,  external  urethrotomy  is  necessary.  A 
fixed  calculus  in  the  prostatic  urethra  should  be  removed  by  median 
perineal  section,  and  the  bladder  explored  for  other  stones.  When 
calculi  are  embedded  in  para-urethral  pockets  the  wall  of  the  pocket 
should  be  carefully  destroyed. 

FOREIGN   BODIES 
A  large  variety  of   foreign  bodies  may  be  found  in  the  urethra?  of  erotic 
individuals,  and  portions  of  surgical  instruments  may  be  accidentally  left 


Soo  THE   URETHRA 

in  the  canal.  The  foreign  body  does  not  remain  for  long  in  the  urethra. 
It  i-  cither  forced  out  by  the  urine  or  removed  by  the  surgeon,  or  it  may 
pass  backwards  into  the  bladder.  When  it  remains  in  the  urethra  there  are 
purulent  discharge,  pain,  burning,  and  haemorrhage,  increased  by  erections. 
Frequent  micturition,  difficulty,  dribbling,  and  sometimes  complete  retention 
of  urine  occur.  The  foreign  body  quickly  becomes  encrusted  with  phosphates. 
Periurethritis  and  periurethral  abscess  may  result.  The  situation  is  usually 
the  fossa  navicularis  or  bulbous  urethra,  rarely  the  prostatic  urethra. 

Treatment.— The  body  may  be  swept  out  by  the  stream  of  urine 
if  the  meatus  is  compressed  during  the  flow  and  then  suddenly  relaxed. 
A  long  firm  body  may  be  pressed  out  from  the  perineum  or  penis.  Meatotomy 
is  frequently  necessary. 

A  pin  with  a  round  head  lies  in  the  urethra  with  the  head  bladderwards 
and  the  point  buried  in  the  mucous  membrane.  The  point  should  be  mani- 
pulated through  the  urethra  and  skin,  and  the  pin  drawn  out.  the  head  reversed, 
and  then  pushed  out  of  the  meatus.  Small  bodies  or  portions  of  catheter 
mav  be  withdrawn  by  means  of  long  fine  urethral  forceps,  and  a  magnet 
has  been  employed  to  remove  an  iron  foreign  body. 

The  urethroscope  is  used  to  diagnose  and  remove  foreign  bodies,  urethral 
forceps  being  passed  along  a  large  urethral  tube. 

If  these  measures  fail,  external  urethrotomy  should  be  performed  and 
the  foreign  body  removed.  When  the  foreign  body  lies  in  the  prostatic  urethra 
it  will  be  easier  to  push  it  back  into  the  bladder  and  deal  with  it  as  a  foreign 
body  of  the  bladder. 

STRICTURE 

Stricture  of  the  urethra  is  congenital,  inflammatory,  or  traumatic. 
The  congenital  variety  has  already  been  described  (p.  886). 

Etiology. — The  female  urethra  is  very  rarely  affected.  Acquired 
stricture  has  been  observed  in  male  infants,  but  the  age  is  usually 
between  20  and  40  years. 

Inflammatorv  stricture  results  from  chronic  urethritis,  which  has 
a  gonorrhceal  origin  in  90  per  cent,  of  cases.  Any  condition  which 
tends  to  prolong  the  inflammation  in  chronic  urethritis,  such  as  a 
narrow  meatus,  phimosis,  injudicious  treatment,  alcohol,  or  exposure, 
acts  as  a  predisposing  cause.  Rarely,  chronic  urethritis  due  to  tuber- 
culosis of  the  urethra  or  diabetes  produces  stricture.  Stricture  has 
followed  a  urethral  chancre  or  a  gumma. 

Pathological  anatomy. — In  traumatic  stricture,  fibrous  tissue 
develops  between  the  severed  ends  of  the  ruptured  urethra,  the 
extent  of  which  depends  upon  the  distance  they  lie  apart,  necrosis 
from  the  injurv,  or  subsequent  sloughing  from  septic  complications. 
The  lesion  develops  rapidly,  is  single,  and  the  seat  of  election  is  the 
bulbous  urethra.  A  thick  tough  mass  of  fibrous  tissue  involves  the 
mucous  and  submucous  coats  and  the  cavernous  tissue,  and  sometimes 
also  the  perineal  tissues  and  skin. 

Gonorrhceal  strictures  are  usually  multiple,  and  most  frequently 
affect  the  bulbous  urethra.  The  prostatic  urethra  is  very  rarely  affected 
in  gonorrhceal  stricture.     The  strictured  portion  of  the  wall  is  confined 


STRICTURE 


tn  b  narrow  circular  band,  bu1  it  may  measure  an  inch  or  more  in 
old-standing  oases,  or  rarely  almost  the  whole  Length  of  the  anterior 
urethra  is  sclerosed.  Complete  obliteration  of  the  Lumen  baa  been 
recorded,  bu1   is  very  rare. 

The  following  terms  bave 
been  applied,  viz. :  '*  annu- 
lar "  si riit ore,  a  fine  band 
involving  the  whole  circum- 
ference (Pig.  550);  "bridle" 
stricture,  an  isolated  band 
stretching  across  the  lumen  ; 
"resilient"  stricture,  an 
elastic  stricture  which  recon- 
tracts  quickly  after  dilata- 
tion ;  "  cartilaginous  "  stric- 
ture, a  hard  fibrous  mass, 
usually  of  considerable  extent. 
In  an  "  irritable  "  stricture 
there  is  a  rise  of  temperature 
or  even  a  rigor  after  each 
instrumentation.  An  ';  im- 
passable "  stricture  is  one 
through  which  no  instrument 
can  be  passed.  A  stricture 
may  affect  the  whole  circum- 
ference of  the  urethra  or 
only  the  floor,  roof,  or  lateral 
walls.  The  lumen  is  central 
or  excentric,  and  it  may  be 
tortuous. 

The  histological  changes 
consist  in  proliferation  of  the 
epithelium,  which  becomes 
squamous,  and  sclerosis  of 
the  subepithelial  tissue,  the 
fibrous  tissue  invading  the 
submucous  tissue,  and  the 
erectile  tissue  of  the  corpus 
spongiosum. 

The  urethra  behind  the 
stricture  shows  chronic  in- 
flammation and  dilatation. 
Vegetations  and  ulcerations 
are  frequently  present.     The 


Fig.  550. — Annular  stricture  of  the 
bulbous  urethra. 


892  THE    URETHRA 

bladder  muscle  is  hypertrophied,  and  cystitis  is  common.  There 
may  be  acute  retention  of  urine  or  chronic  vesical  distension.  The 
ureters  and  eventually  the  kidneys  become  dilated,  and  ascending  septic 
pyelonephritis  is  usually  present  in  old-standing  cases. 

Symptoms. — In  stricture  of  large  calibre  the  only  symptom 
may  be  a  persistent  purulent  discharge  (gleet).  In  stricture  with  small 
lumen  the  stream  is  small,  thin,  twisted,  forked,  or  sprayed,  or  it  may 
appear  in  small  jets  or  only  in  drops.  The  projection  is  feeble,  there 
may  be  a  pause  before  micturition  commences,  and  the  stream  finishes 
in  a  dribble.  Frequent  micturition  is  usually  due  to  chronic  urethritis 
of  the  prostatic  urethra  or  to  cystitis.  Pain  may  be  felt  at  the  seat 
of  the  stricture  during  micturition,  at  the  external  abdominal  rings, 
or  in  the  back  over  the  kidney  on  one  or  both  sides.  Pain  on  ejacula- 
tion and  backward  flow  of  semen  into  the  bladder  occur  and  are  a 
cause  of  sterility. 

Retention  of  urine  may  be  transient,  lasting  a  few  minutes  or 
half  an  hour.  Acute  total  retention  of  urine  is  caused  by  a  chill, 
dietetic  or  alcoholic  indiscretion,  or  sexual  excess.  There  is  severe 
suprapubic  cramping  paroxysmal  pain,  the  patient  is  pale  and  sweating, 
and  the  bladder  is  felt  as  an  oval  suprapubic  swelling.  No  urine 
escapes,  or  only  a  few  drops  from  time  to  time.  In  some  cases  there 
is  a  remarkable  absence  of  pain.  Retention  of  urine  is  due  to  spasm 
of  the  compressor  urethraa  muscle  or  congestion  of  the  mucous  mem- 
brane at  the  stricture.  Incontinence  of  urine  is  observed  in  narrow 
strictures.  A  small  quantity  of  urine  may  be  retained  in  the  urethra 
behind  the  stricture  and  dribble  away  after  micturition.  Involuntary 
dribbling  of  urine  is  observed  when  the  bladder  is  chronically  over- 
distended. 

In  the  later  stages  chronic  cystitis  is  present,  and  there  is  frequent 
and  painful  micturition  day  and  night.  In  long-standing  stricture 
dilatation  and  septic  infection  of  the  ureters  and  kidneys  lead  to 
symptoms  of  urinary  septicaemia  and  of  renal  failure. 

Examination. — A  cartilaginous  stricture  can  be  felt  on  palpa- 
tion, and  becomes  more  distinct  when  a  bougie  is  passed. 

To  detect  a  stricture  a  large  gum-elastic  bougie  (No.  20  F.  or  21  F.) 
should  be  introduced  along  the  urethra  ;  it  is  arrested  by  the  stricture. 
Spasm  of  the  compressor  rarely  causes  obstruction  sufficient  to 
resist  gentle  pressure  with  a  bougie  of  this  size.  Smaller  instru- 
ments are  now  passed  until  one  is  found  which  will  enter  the  lumen 
of  the  stricture.  In  strictures  of  comparatively  large  calibre  an  acorn- 
tipped  bougie  is  used.  The  acorn  tip  passes  through  the  stricture, 
and  on  being  withdrawn  the  shoulder  of  the  acorn  hitches  at  the 
stricture  and  the  length  of  the  stricture  can  be  ascertained.  The 
aero-urethroscope  is  useful  in  diagnosing  strictures  of  wide  calibre. 


STRICTURE:    TREATMENT  893 

Diagnosis.  I  Spasm  <>f  the  compressor  urethras  (spasmodic 
stricture)  La  caused  by  acute  or  chronic  inflammation  of  the  prostatic 

urethra.  The  difficult  micturition  is  here  intermittent  in  character; 
the  obstruction  lies  in  the  position  of  the  membranous  urethra, 
gentle  continuous  pressure  succeeds  in  overcoming  thifi  resistance, 
and  the  aero-urethroscope  shows  the  contracted  membranous  urethra. 

2.  Malignant  disease  of  the  prostate  gives  rise  to  increasing  diffi- 
culty of  micturition.     The  1  nset  of  symptoms  in  stricture  dates  from 
a  much  earlier  age,  and  the  position  of  the  obstruction 
examination  are  sufficient  to  make  a  diagnosis. 

Complications. — The  following  are  complications  that  may  be 
observed  : — 

1.  Retention  of  urine. 

2.  Septic  complications  (acute  or  chronic  urethritis,  periurethral 

abscess,  acute  or  chronic  prostatitis,  epididymitis,  cystitis, 
pyelonephritis,  pyonephrosis). 

3.  Extravasation  of  urine. 

4.  Fistula. 

5.  Stone  in  the  urethra. 

6.  Malignant  growth  of  the  urethra. 

Treatment  by  dilatation — Metal  instruments  or  flexible 
bougies  of  silk  or  cotton  web  are  used.  The  surgeon  stands  on  the 
left  of  the  patient  and  handles  'the  instrument  with  his  right  hand 
while  he  manipulates  the  penis  with  the  left. 

In  introducing  a  metal  instrument  the  tip  is  inserted  into  the  meatus 
while  the  shaft  lies  transversely  across  the  left  Scarpa's  triangle.  The 
handle  is  carried  towards  the  patient's  abdomen  and  onwards  to  the 
middle  line,  and  gradually  raised.  The  left  hand  leaves  the  penis 
and  is  used  to  support  the  perineum.  The  handle  is  now  raised  to 
the  vertical  and  swings  down  between  the  thighs,  being  transferred 
to  the  left  hand.  In  passing  elastic  bougies  the  penis  is  grasped  behind 
the  glans  and  the  organ  kept  on  the  stretch.  The  bougie  is  introduced 
and  lightly  held  by  the  forefinger  and  thumb  of  the  right  hand.  If 
the  bougie  is  arrested  it  is  withdrawn  a  little  and  again  pushed  gently 
on.  If  this  fails,  progressively  smaller  instruments  should  be  used 
until  the  size  that  will  pass  is  reached.  A  filiform  bougie  should  only 
be  used  after  larger  instruments  have  failed  ;  if  it  does  not  pass,  the 
end  may  be  bent  to  an  angle  and  the  face  of  the  stricture  searched 
around  its  periphery.  Assistance  may  be  obtained  by  introducing 
a  syringeful  of  oil  into  the  urethra  and  gripping  the  meatus  to  retain 
the  oil.  If  this  is  unsuccessful  a  number  of  filiform  bougies  may  be 
passed  together  down  to  the  stricture  and  each  tried  in  succession. 
An  instrument  sometimes  passes  readily  when  the  patient  is  placed 
under  an  ansesthetic,  or  under  spinal  analgesia,  when  all  other  methods 


s94 


THE   URETHRA 


have  failed.  If  these  attempts  fail  and  no  retention  is  present, 
the  patient  is  replaced  in  bed  and  a  brisk  purge  administered.  A 
further  trial  will  usually  be  successful. 

Most  strictures  are  amenable  to  instrumental  dilatation.  Dilata- 
tion is  carried  out  in  three 
ways — (a)  as  intermittent  dila- 
tation, (b)  as  rapid  dilatation, 
(c)  as  continuous  dilatation. 
Intermittent  dilatation  is  the 
method  of  treatment  of  the 
majority  of  strictures.  A  bougie 
which  fits  the  stricture  is  found, 
and  progressively  larger  instru- 
ments, rising  one  size  at  each 
interview,  are  passed  at  inter- 
vals of  at  first  four  or  five  days, 
and  then  a  week,  and  when 
the  size  reaches  18  or  20  F. 
a  fortnight's,  and  then  three 
weeks',  interval  is  allowed.  As 
the  larger  sizes  are  reached,  the 
intervals  are  extended  to  two, 
three,  four  months,  and  finally 
six  months  and  a  year.  Above 
the  size  of  22  F.  steel  instru- 
ments should  be  employed. 

The  urethra  should  be 
washed  before  and  after  the 
passage  of  an  instrument,  and 
urinary  antiseptics  administered. 
Strictures  which  have  not  be- 
come tough  and  leathery  from 
long  duration,  irregular  treat- 
ment, or  chronic  inflammation 
will  be  completely  relieved  by 
this  method. 

Continuous  dilatation  is  use- 
ful in  cases  where  retention  of  urine  has  complicated  a  very  nairow 
stricture.  The  patient  is  confined  to  bed,  a  filiform  bougie  passed 
and  fastened  in,  and  the  urine  trickles  alongside.  At  intervals  of 
twelve  hours  a  progressively  larger  instrument  is  substituted  until  the 
stricture  permits  the  entrance  of  a  medium-sized  bougie.  Inter- 
mittent dilatation  is  then  substituted. 

Rapid  dilatation  consists  in  passing  bougies  of  increasing  size  in 


Fig.   551. — Stricture  of  the  bulbous 
urethra,  with  recent  false  passage. 


STRICTURE:   OPERATIVE   TREATMENT  895 

quick  succession  through  the  stricture  until  a  Large  size  is  reached. 
This  method  ruptures  the  stricture,  although  the  epithelial  covering 

may   remain   intact,   and    lends   t<>   the   developmenl    ol    a    denser 
stricture  at   a   later  date. 

Complications  of  dilatation.  1.  False  passage  (Fig.  551). — 
Blood  appears  at  the  meatus,  and  a  peculiar  sensation  of  grating 
is  felt.  The  urethra  should  be  washed  with  warm  boric  lotion  to 
which  tincture  of  haniamelis  is  added.  Further  inst  rumental  ion 
should  be  postponed  for  a  week. 

2.  Infection. — This  is  prevented  by  the  sterilization  of  instru- 
ments, the  lubricant,  the  hands,  the  washing  of  the  penis  and  urethra, 
and  the  administration  of  urinary  antiseptics  before  the  passage  of 
instruments.  Urethral  lavage  with  permanganate-of-zinc  solution 
(1  in  5,000)  quickly  cures  the  urethritis. 

Cystitis  and  Ascending  Pyelonephritis  are  considered  under  those 
headings  (pp.  860,  802). 

3.  Syncope. — Faintness  or  actual  syncope  may  occur.  The  patient 
should  be  recumbent  when  instruments  are  passed. 

The  usual  remedies  for  syncope  are  adopted.  On  succeeding  instru- 
mentations a  solution  of  eucaine  (8  per  cent.)  should  be  injected  into 
the  urethra  before  the  instrument  is  passed. 

Operative  treatment. — In  a  certain  number  of  cases  a 
cutting  operation  becomes  necessary.  The  following  are  the  indica- 
tions for  operation  : — 

A.  Gradual  dilatation  may  have  failed. 

1.  Cartilaginous  stricture. 

2.  Resilient  stricture. 

3.  Irritable  stricture. 

4.  Haemorrhage. 

5.  Recurrent  epididymitis. 

6.  Recurrent  retention  of  urine  after  instrumentation. 

7.  Periurethral  abscess  and  extravasation  during  the  course  of 

dilatation. 

B.  Cases  unsuitable  for  dilatation. 

1.  Impassable  stricture. 

2.  Urethral  complications  such  as  stone,  periurethral  abscess, 

extravasation  of  urine,  fistula. 

3.  The  stricture  complicates  enlargement  of  the  prostate,  stone, 

tuberculosis,   chronic    cystitis,  and  new    growths   of  the 
bladder. 

4.  Renal  complications. 

C.  The  patient  is  unable  or  unwilling  to  carry  out  dilatation. 

1.  Residence  beyond  reach  of  regular  medical  aid. 

2.  Want  of  time. 


896  THE   URETHRA 

Internal  urethrotomy. — This  consists  in  cutting  the  stricture 
by  means  of  a  specially  guarded  knife  (urethrotome)  introduced  along 
the  urethra.  A  filiform  guide  is  passed  through  the  stricture,  the  fine 
grooved  staff  is  screwed  on  to  it  and  follows  it.  A  triangular  knife  is 
run  along  the  groove  and  cuts  the  stricture.  A  catheter  is  tied  in 
the  urethra  for  forty-eight  hours.  Large  metal  instruments  are  passed 
at  increasing  intervals  after  the  operation.    ■ 

Results.— Of  1,018  patients  treated  for  stricture  by  internal  urethrotomy 
at  St.  Peter's  Hospital,  8  died  (078  per  cent,).  The  causes  of  death  were: 
(1)  exacerbation  of  old-standing  pyelonephritis  (50  per  cent.)  ;  (2)  anuria 
and  uraemia  ;    (3)  septicaemia  ;    (4)  haemorrhage. 

Internal  urethrotomy  usually  affords  complete  relief  if  followed  by  the 
passage  of  instruments  at  long  intervals.  If  after-dilatation  is  neglected, 
recontraction  of  the  stricture  is  common. 

External  urethrotomy  with  a  guide  (Syme's  opera- 
tion).— The  stricture  is  dilated  to  a  No.  4  English  gauge  and  a  Syme's 
staff  introduced.  The  patient  is  placed  in  the  lithotomy  position, 
and  an  incision  made  on  the  staff  just  above  its  shoulder  and  carried 
back  through  the  stricture  to  the  membranous  urethra.  A  gorget 
is  introduced  and  guides  a  perineal  drainage-tube  into  the  bladder. 

External  urethrotomy  without  a  guide. — The  following 
operations  are  undertaken  when  the  surgeon  has  failed  to  pass  an 
instrument  through  the  stricture  : — 

(a)  Wheelhouse's  operation. — A  Wheelhouse  staff  is  passed  down  to 
the  stricture  and  an  incision  made  upon  it  about  1  in.  from  the  end. 
The  staff  is  hooked  in  the  upper  end  of  the  wound,  the  mucous  mem- 
brane picked  up  on  each  side,  and  careful  search  made  for  the  opening. 
When  this  is  found  a  probe  is  passed  through  the  stricture,  which  is 
then  slit  up  and  the  operation  finished  as  in  Syme's  method. 

(b)  If  Wheelhouse's  operation  fails,  the  incision  is  carried  back 
and  exposes  the  dilated  urethra  behind  the  stricture  ;  a  probe  is 
passed  through  the  stricture  from  behind  forwards,  and  the  scar 
tissue  slit  on  this. 

(c)  Code's  operation  was  originally  introduced  for  cases  of  acute 
retention  in  impassable  stricture.  The  tip  of  the  left  forefinger  is  placed 
in  the  rectum  on  the  apex  of  the  prostate,  and  a  knife  entered  in  the 
middle  line  of  the  perineum  |  in.  in  front  Of  the  anus  and  pushed 
straight  for  this  point.  The  dilated  urethra  behind  the  stricture  is 
opened. 

(d)  Suprapubic  cystotomy  and  retrograde  catheterization  followed 
by  perineal  section  has  little  to  recommend  it  over  the  perineal  dis- 
section (&). 

Results  of  external  urethrotomy.— The  mortality  was  8  per  cent,  in  100  cases 
at  St.  Peter's  Hospital.  Gregory  found  a  mortality  of  8-8  per  cent,  in  992 
cases.     Bougies  should  be  passed  at  regular  intervals  after  the  operation. 


PERIURETHRITIS  »97 

Excision  of  strictures.— A  angle  stricture  of  moderate  dimen- 
sions  may  be  resected.  The  whole  thickness  < »f  the  spongy  body  i-^ 
removed  with  the  stricture,  and  the  severed  ends  i  irefully  united. 
The  urine  is  drained  for  a  fortnight  through  a  suprapubic  opening. 
Satisfactory  results  have  been  obtained,  l>ut  the  operation  is  limited 
in  applicability. 

PERIURETHRITIS    AXD    PERIURETHRAL   SUPPURATION 

The  source  of  infection  is  the  urethra,  and  the  inflammation  takes 
various  forms,  such  as  abscess,  masses  of  fibrous  tissue,  gangrenous 
or  phlegmonous  inflammation  ("  extravasation  of  urine"). 

Etiology. — The  urethra   is  usually  tl  of    stricture,   but 

injury  during  instrumentation  or  internal  urethrotomy,  new  growths 
of  the  urethra,  foreign  bodies,  calculi,  or  a  retained  metal  catheter 
may  be  the  predisposing  cause.  There  is  usually  a  mixed  infection  of 
Bacillus  coli,  streptococcus,  and  staphylococcus  ;  rarely  one  of  these 
is  present  in  pure  culture.  Anaerobic  bacteria  are  usually  found 
mixed  with  aerobic  bacteria,  but  occasionally  alone.  They  are  especi- 
ally frequent  in  phlegmonous  periurethritis  ("  extravasation  of  urine  "), 
Inflammation  spreads  either  by  thrombosis  in  the  corpus  spongiosum 
or  by  the  spread  of  inflammation  along  the  urethral  gland  ducts. 

Periurethral  Abscess  (Urinary  Abscess). 

The  abscess  may  develop  in  relation  to  the  penile  or  bulbous 
urethra  during  the  course  of  acute  gonorrhoea  or  chronic  urethritis. 
A  tender  swelling  appears  on  the  under-surface  of  the  penis,  and  by 
rupture  both  externally  and  into  the  urethra  may  establish  a  urinary 
fistula. 

Abscess  around  the  bulbous  urethra  may  develop  insidiously  and 
form  a  hard,  tender  nodule,  or  may  commence  with  a  rigor  and  run  an 
acute  course  with  fever,  local  tenderness  and  pain,  and  rapid  forma- 
tion of  a  swelling.  The  swelling  is  limited  posteriorly  at  the  middle 
of  the  perineum  by  the  fascia  of  Colles.  but  passes  forwards  under 
cover  of  the  scrotum.  Partial  or  complete  retention  of  urine  is  fre- 
quently present. 

Treatment. — A  penile  periurethral  abscess  in  the  anterior  part 
of  the  canal  should  be  opened  through  the  urethra  with  the  help  of  a 
wire  speculum  or  a  short  urethral  tube.  A  perineal  periurethral 
abscess  is  opened  by  a  free  median  perineal  incision,  and  the  cavity 
flushed  with  biniodide  solution.  All  pockets  are  opened,  counter- 
openings  made  if  necessary,  and  the  cavity  freely  drained  and  lightly 
packed  with  iodoform  gauze.  "When  a  narrow  stricture  and  cystitis 
coexist  a  median  perineal  cystotomy  with  drainage  of  the  bladder 
should  be  performed. 
3  f 


SpS  THE   URETHRA 

Diffuse  Phlegmonous  Periurethritis  (Extravasation 
of  Urine) 

This  is  a  virulent,  rapidly  spreading  infection,  with  sloughing 
of  the  urethra.  Stricture  is  usually  present,  but  is  not  necessarily 
narrow,  and  may  even  be  absent.  The  condition  rarely  commences 
as  a  periurethral  abscess.  Usually  the  onset  is  sudden,  and  the  symp- 
toms at  once  become  severe.  After  a  rigor  the  temperature  rises  to 
102°  F.,  or  higher,  and  profound  toxasmia  rapidly  develops.  The 
patient  is  pale,  and  the  skin  clammy ;  the  tongue  and  mouth  are 
dry,  and  delirium  quickly  appears.  The  urine  is  passed  with  diffi- 
culty and  in  small  quantity.  A  dull-red,  brawny  induration  appears 
in  the  perineum  and  rapidly  increases.  The  spread  is  limited  by  the 
attachment  of  Colles's  fascia  behind  the  transverse  perineal  muscle 
posteriorly  and  to  the  rami  of  the  pubes  laterally.  The  scrotum 
becomes  red  and  cedematous,  the  penis  swollen  and  distorted,  and  the 
infiltration  rapidly  mounts  on  to  the  pubes  and  abdominal  wall. 
Crepitation  from  the  formation  of  gas  is  sometimes  detected.  A 
fatal  result  from  toxaemia  is  not  uncommon,  and  may  occur  after 
operation. 

Treatment.  —  Immediate  multiple  incisions  should  be  made 
wherever  the  infection  has  spread,  and  washed  through  several  times 
in  the  twenty-four  hours  with  hydrogen  peroxide  or  biniodide  solu- 
tion (1  in  2,000).  Hot  fomentations  should  be  applied,  stimulants 
freely  administered,  and  subcutaneous  and  rectal  saline  infusions 
given.  Sloughing  of  the  urethra  occurs,  and  fistulas  form  and  later 
require  treatment. 

Chronic  Indurative  Periurethritis 

There  is  a  stricture  of  the  bulbous  urethra,  usually  of  the  irregular 
cartilaginous  type,  and  large  masses  of  fibrous  induration  form  in  the 
perineum  and  scrotum.  There  are  usually  several  urinary  fistula?, 
and  the  indurated  mass  frequently  contains  one  or  several  small 
abscesses.  Calculi  may  form  in  the  fistulas  and  behind  the  stricture, 
and  a  malignant  growth  has  been  known  to  develop. 

Treatment. — Internal  urethrotomy  should  be  performed  and  a 
catheter  tied  in  as  a  preliminary  to  operation  on  the  periurethral 
induration  a  week  or  more  later.  If  the  stricture  is  impassable,  external 
urethrotomy  is  performed  at  the  time  of  the  perineal  operation. 

A  staff  is  placed  in  the  urethra,  and,  with  the  patient  in  the  litho- 
tomy position,  the  indurated  mass  is  split  down  the  centre  to  the 
corpus  spongiosum  and  each  half  dissected  away,  removing  fistulas 
and  small  abscesses  in  the  substance  of  the  mass.  The  opening  in 
the  urethra  is  repaired  with  catgut  sutures  and  a  catheter  tied  in  the 
urethra. 


UKKTMKAL    FISTULA 


899 


Fig.  552. — Acquired  defect  of  urethra  after 
removal  of  large  urethral  calculus. 


FISTULA    AND     \<  «»l  1RED   DEFECTS 

Urethral  fistulse  may  open  on  to  the  skin  of  the  penis,  Bcrotum,  perineum, 
groin,  gluteal  region,  or  into  the  reotum. 

Etiology.  Congenita]  defects  may  take  the  form  of  hypospadias  or 
epispadias  (pp.  906,  9G7).  The  most  common  congenita]  form  is  a  fistula  of 
the  membranous  or  prostatic  urethra,  and  is  combined  with  atresia  ani,  and  the 
perinea]  muscles  may 
be  atrophied.  Acquired 
fistula  arises  from 
trauma,  inflammation, 
or  new  growth.  Trauma- 
tic fistula  arises  from 
within  the  urethra  from 
false  passages  and 
sloughing  due  to  tying 
in  a  metal  catheter,  and 
from  without  by  stabs, 
impaling,  bullet  wounds, 
etc.,  or  after  surgical 
operations  such  as  ex- 
ternal urethrotomy  (Fig. 
552),  perineal  prostatec- 
tomy, and  after  opening 
or  rupture  of  a  peri- 
urethral abscess  or  the 
incision  of  gangrenous 
periurethritis.  Tubercu- 
lous disease  and  bilhar- 
ziosis  are  rare  causes. 

Symptoms. — 
Urine  escapes  from  the 
fistula  during  micturi- 
tion. The  symptoms  of 
stricture  are  also  present. 
Fistula  of  the  penile 
urethra  usually  opens 
directly  into  the  ure- 
thra, and  is  surrounded 
by  a  firm  ring  of  fibrous 
tissue.  In  perineal  fis- 
tula there  may  be  one  or 
several  openings.  The 
fistulae  are  surrounded 
by  hard,  fibrous  indura- 
tion. In  urethro-rectal 
fistula  the  urine  is  dis- 
charged into  the  rectum  at  each  micturition,  and  produces  a  watery  motion. 
Gas  may  be  passed  along  the  urethra  and  faecal  matter  escape  with  the 
urine.     Urethritis  and  cystitis  are  usually  present. 

Treatment.— The  treatment  of  fistula  with  massive  induration  has 
already  been  discussed.  In  cases  without  induration  the  stricture  is  dilated, 
or  internal  urethrotomy  performed  and  a  catheter  tied  in  the  urethra  for 
a  week.     The  fistula  is  scraped  and  cauterized,  or  dissected  down  to  the 


Fig. 


553. — Result    of   plastic    operation   for 
repair  of  defect :    same  case. 


9oo  THE    URETHRA 

urethra,  the  opening  in  that  canal  closed,  and  the  bladder  drained  supra- 
pubically  for  a  fortnight.  In  larger  defects,  plastic  operations  are  necessary 
(Fig.  553).  For  fistula  at  the  base  of  the  glans  penis  the  edges  of  the  fistula 
are  excised,  and  the  raw  surfaces  united  with  catgut  and  covered  with  a  flap 
of  skin  from  the  penis  (Dieffenbach's  operation).  For  fistula  on  the  under- 
surface  of  the  penis  various  flap  operations  have  been  used.  For  the  repair 
of  extensive  urethral  defects  the  operations  are  autoplastic  or  heteroplastic. 
In  the  former  a  defect  in  the  floor  of  the  bulbous  urethra  is  repaired  by 
uniting  longitudinal  flaps  over  a  catheter  and  covering  these  by  undercut- 
ting and  approximating  the  skin.  The  latter  methods  are  suitable  for 
cases  where  portions  of  the  urethra  have  been  completely  destroyed  or 
removed. 

Portions  of  tissue  from  other  parts  of  the  patient's  body  have  been  used, 
such  as  the  foreskin,  mucous  membrane  from  the  lower  lip,  or  the  long 
saphenous  vein.  Mucous  membrane  has  also  been  transplanted  from  other 
human  beings,  such  as  the  mucous  membrane  of  a  prolapsed  uterus, 
and  from  bullocks,  goats,  and  birds.  The  results  of  these  operations  have 
varied,  but  the  autoplastic  have  been  more  satisfactory  than  the  hetero- 
plastic. 

In  urethro-rectal  fistula,  stricture,  calculi,  and  other  complications  should 
first  be  treated,  and  the  bladder  drained  suprapubicalh'.  A  curved  prerectal 
incision  is  made,  and  the  urethra  and  rectum  dissected  apart.  The  fistula  is 
cut  across  and  the  openings  sutured.  The  rectum  may  be  twisted  so  as  to 
remove  the  sutured  fistulas  from  immediate  proximity. 

NEW    GROWTHS 

Growths  are  comparatively  rare,  the  male  urethra  being  more  frequently 
affected  than  the  female.  The  benign  growths  met  with  are  papilloma, 
fibroma,  caruncle,  myoma,  adenoma,  and  cysts  ;  the  malignant,  carcinoma 
and  sarcoma.  Gonorrhoea  is  said  to  play  an  important  part  in  their  etiology. 
In  the  male  papilloma  and  adenoma,  and  in  the  female  caruncle,  are  the  most 
frequent  forms  of  growth. 

Benign  Growths  :    Papilloma 

Papillomas  are  found  in  the  anterior  urethra,  rarely  in  the  prostatic 
urethra,  and  resemble  those  met  with  on  the  glans  penis  and  foreskin.  There 
is  a  purulent  discharge,  and  sometimes  a  peculiar  sensation  during  micturi- 
tion. The  diagnosis  is  made  with  the  urethroscope.  The  growths  bleed 
very  readily,  and  are  easily  torn  by  the  passage  of  instruments.  There  may 
be  a  few  isolated  growths,  or  the  urethra  may  be  choked  with  papillo- 
matous masses.  The  warts  should  be  removed  through  the  urethroscope. 
Urethral  forceps  or  a  specially  constructed  urethroscope  tube  is  used  for 
the  purpose,   and  the  bases  are  touched  with  nitrate  of  silver. 

Polypi 

Urethral  polypi  usually  occur  in  the  prostatic  urethra,  springing  from 
the  verumontanum  or  close  to  it,  rarely  in  the  anterior  urethra.  Two  forms  are 
found — (1)  fibroma,  which  consists  of  loose  fibrous  tissue  covered  by  a  thin 
layer  of  mucous  membrane ;  (2)  adenoma,  in  which  there  are  numerous  gland 
follicles  having  appearances  identical  with  those  of  the  "  hypertrophied " 
prostate.  Myoma  and  fibro-niyorna  have  also  been  described.  A  chronic 
urethral  discharge  is  usually  present,  but  may  consist  of  only  a  few  shreds 


I  KITHRAL   CYSTS 


901 


or  may  he  absent,  Tickling  and  craw  lii^  sensations  arc  some!  inns  experienced, 
and  hemorrhage  follows  instrumentation.  The  polypus  is  discovered  by  the 
urethroscope,  and  i--  removed  by  fine  alligator  forceps  or  the  electro-cautery. 


Cysts 

Small  cysts  an-  produced  by  blocking  the  urethral  lacuna.  Cysts  of  the 
sinus  pocularis  are  rare.  A  cyst  of  Cowper's  gland  or  ducts  may  form  a  con- 
siderable swelling  which  ruptures 
into  the  urethra.  The  treatment 
consists  in  incision  with  the  electric 
cautery  through  the  urethroscope 
tube. 

Caruncle 

Urethral    caruncle    is   discussed 
at  p.  989. 

Malignant  Growths  of  the 
Male  Urethra 

Malignant  growths  of  the  male 
urethra  are  rare.  Hall  collected 
48  examples.  In  addition  to  these, 
Barney  records  2  cases,  and  I 
have  had  4  under  my  care.  The 
condition  usually  occurs  between 
the  ages  of  50  and  60,  rarely  before 
40.  Trauma  and  leucoplakia  from 
chronic  urethritis  are  important 
factors  in  the  etiology,  and  stricture 
is  present  in  half  the  cases.  The 
bulbous  urethra  is  usually  affected, 
less  often  the  penile  urethra,  and 
rarely  the  prostatic  portion.  The 
growth  takes  the  form  of  a 
squamous  epithelioma,  very  seldom 
a  sarcoma.  It  infiltrates  and  destroys 
the  mucous  membrane  and  invades 
the  corpus  spongiosum.  Eventually 
fistulae  form  in  the  perineum. 

Symptoms.— The  symptoms 
vary    considerably.      There    is    in- 
creasing difficulty,  partly  due  to  the  fibrous  stricture  already  present.    Haemor- 
rhage follows  the  passage  of  an  instrument,  and  there  may  be  a  bloody  dis- 
charge without  instrumentation.     A  purulent  discharge  is  frequently  present. 

A  swelling  appears  in  the  perineum  in  some  cases,  the  skin  becomes  red, 
and  either  a  fistula  forms  spontaneously,  or  the  swelling  is  incised  for  a  simple 
periurethral  abscess.  The  growth  then  fungates,  and  progressive  destruction 
of  the  perineal  tissues  takes  place  (Fig.  554).  In  the  penile  urethra  hard 
induration  of  the  wall  of  the  canal  is  felt,  which  slowly  increases  and  spreads. 
The  penis  is  ventrally  curved  during  erection,  and  becomes  swollen  into  a 
club-like  form.  Uretliral  examination  shows  a  fibrous  stricture  through 
which  the  instrument  may  enter  an  irregular  cavity  with  friable,  readily 
bleeding  walls.    Urethroscopy  may  give  a  view  of  the  growth.    Lymph-glands 


Fig.  554. — Malignant  growth  of 
urethra  ulcerating  on  perineum 
and  scrotum,  and  round  anus. 


902  THE    URETHRA 

are  affected  later,  those  along  the  iliac  vessels  and  in  the  groins  being  first 
involved.     Metastases  occur  in  the  bones,  liver,  and  lungs. 

The  diagnosis  from  stricture  is  usually  difficult.  Spontaneous  haemor- 
rhage from  the  urethra,  repeated  severe  haemorrhage  after  instrumentation, 
and  persistent  haematuria  are  important  symptoms.  From  subacute  and 
chronic  periurethritis  and  from  periurethral  abscess  the  diagnosis  is  some- 
times only  made  by  exploratory  operation. 

Treatment. — Resection  of  the  urethra  has  been  performed  in  the 
early  stage,  and  amputation  of  the  penis  has  given  good  results,  but  when 
the  growth  is  extensive,  complete  removal  of  the  penis  (Thiersch-Gould 
operation)  is  necessary. 

Malignant  Growths  of  the  Female  Urethra 

These  are  periurethral  or  urethral.  The  former  occur  after  the  age  of 
50,  and  the  latter  earlier.  The  urethral  variety  may  be  pedunculated  or 
sessile,  appearing  as  a  dark-red  grape-like  polypus  or  a  nodular  ulcerated 
area.  The  growths  are  squamous  or  rarely  columnar  epithelium,  or  sarcoma. 
There  is  pain  on  micturition,  on  coitus,  and  on  sitting  and  walking,  frequent 
micturition,  difficulty,  and  occasionally  complete  retention.  Incontinence  is 
rare,  haematuria  is  usually  present.  The  urethra  may  be  excised  by  a  longi- 
tudinal incision  on  the  anterior  wall  of  the  vagina.  The  vesical  end  is,  if 
possible,  preserved  and  implanted  in  the  vaginal  wall. 

TUBERCULOSIS  OF  THE  URETHRA  AND  PENIS 

Tuberculosis  of  the  urethra  is  rare.  Primary  tuberculosis  has  been  ob- 
served, but  the  infection  is  almost  invariably  secondary  to  tuberculosis  of 
the  urinary  or  genital  system.  The  female  urethra  is  seldom  affected.  In  the 
male,  the  posterior  urethra  is  usually  attacked  by  spread  from  the  prostate  or 
the  bladder.  A  deep  tuberculous  cavity  may  open  from  the  substance  of  the 
prostate  into  the  posterior  urethra,  or  there  may  be  superficial  ulceration  or 
tuberculous  granulation  tissue.  The  anterior  urethra  may  show  small  super- 
ficial ulcers.  If  the  penis  is  affected  the  urethral  mucous  membrane  is  involved 
in  the  tuberculous  infiltration.  A  periurethral  cold  abscess  may  form,  and 
eventually  fistulae  appear  in  the  perineum. 

Stenosis  of  the  urethra  is  occasionally  observed  in  the  bulbous  or  female 
urethra  in  cases  of  urinary  or  genital  tuberculosis.  There  is  seldom  a  localized 
stricture,  but  the  wall  is  infiltrated,  and  an  irregular  fibrous  thickening 
results. 

A  urethral  discharge  is  always  present,  usually  thin  and  pale,  but  occasion- 
ally so  abundant  and  purulent  and  associated  with  symptoms  so  acute  as  to 
suggest  gonorrhceal  urethritis.  Haematuria,  frequent  and  difficult  micturi- 
tion, and  occasionally  complete  retention  may  be  present.  There  is  irregular 
periurethral  induration. 

Tuberculosis  of  the  penis  may  be  confined  to  ulceration  of  the  glans, 
usually  on  the  under  surface,  or  the  corpora  cavernosa  may  be  invaded. 

Treatment. — Urethral  tuberculosis  is  so  seldom  an  isolated  lesion 
that  separate  treatment  is  rarely  necessary.  Stricture  should  be  treated  by 
internal  urethrotomy  and  dilatation.  A  cold  abscess  is  opened  and  tincture 
of  iodine  applied.  Fistulae  are  treated  by  scraping  and  injection  of  iodoform 
emulsion,  bismuth  paste,  or  iodine. 

Conservative  treatment  should  be  adopted  when  the  penis  is  involved 
but  amputation  may  become  necessary  for  extensive  lesions.  Tuberculin 
may  be  administered. 


BIBLIOGRAPHY  903 

BIBLIOGB  M'llY 

II  1  \i  \  11  i;i  v 

Klotzenberg.   Zeits.  f.  Urol.,   L908,  p.   L25 

Pilcher,    Ann.  of  Surg.,  L909,  p.  652. 

White.  Hale,   Quart.   Journ.  of  Med.,  L911,  p.  509. 

CONGENITAL   ABNORMALITIES   OV  THE    KlUNKY 

Albarran,    Ann.  des  Mai.  dee  Org.  Gin.-Urin.,  1908,  p.   1601. 
Ballowitz,    Virchovfe    Arch.,  L895,  oxli  309. 
Heiner,  Folia    Urol.,  Oct.,  1908. 

Movable  Kidney 
Billington,  Movable   Kidney.     London,  1910. 
Cheyne,  Sir  W.  Watson,  Lancet,  April  24,  1909. 
Lane,  Arbuthnot,  Lancet,  Jan.  17,  1903. 
Walker,  Thomson,  Lancet,  Aug.  11,  1906. 
Wolkow  and  Delitzen,  Die  Wanderniere.     Berlin,  1899. 

Injuries  of  the  Kidney 
Curschmann,  Munch,  med.  Woch,,  1902,  xlix.  38. 
Riese,   Arch.  f.  klin,  Chir.,  1903,  vol.  lxxi. 
Watson,   Boston  Med.  and  Surg.    Journ.,  July  9  and  Id,   1903. 

Perinephritis 
Guiteras,    N.Y.  Med.   Journ.,  1906,  lxxxiii.  169. 
Townsend,   Journ.    Amer.  Med.    Assoc,  1904,  xliii.   1626. 
Zuckerkandl,  Wien.  klin.  Woch.,  Oct.  13,  1910 

Pyelonephritis  and  Pyelitis 
Brewer,  Surg.,  Gyn.,  and  Obstet.,  June,  1908,  p.  699. 
Cova,    Ann.  di  Obstet.  e  di  Ginecol.,  1903,  p.  692. 
Dudgeon,  Lancet,  1908,  i.  616. 

Legueu,    Ann.  des  Mai.  des  Org.   Gen,-  Urin.,  1904,  p.   1441. 
Morse,    Amer.   Journ.  of  Med.  Sci.,  1909,  p.  313. 
Pousson,  Folia    Urol.,  Jan.,  1909,  p.  445. 

Sampson,   Johns  Hopkins  Hosp.  Bull.,  1903,  Xo.   153,  p.  336. 
Thomson,  Scot.  Med.  and  Surg.   Journ.,  1902,  p.  7. 
Walker,  Thomson,  Pract.,  May,  1911. 

Pyonephrosis 
Cahn,  Miinch.  med.  Woch.,  1902,  xlix.  19. 
Greaves,   Brit.  Med.    Journ,,  July  13,  1907. 
Morris,  Sir  Henry,  Lancet,  1910,  i.  1597, 
Watson,   Ann.  of  Surg.,  1908,  No.  3. 

Renal  and  Perirenal  Fistul.e 
Heitz-Boyer  et  Moreno,  Ann.  des  Mai.  des  Org.  Gen.- Urin.,  1910,  Xo.  II. 

XON-SUPPURATIVE    XEPHRITIS 

Edebohls,  Med.    News,  April  22,  1899,  and  Med.   Bcc..  Mar  4,   1901. 
Pousson,   Chir.  des  Nephrites,  Paris,  1909. 
Walker,  Thomson,  Pract.,  June,  1903. 

Hydronephrosis 
Israel,  Deuts.  med.  Woch.,  1906,  p.  22. 
Mayo,   Journ,    Amer.  Med.    Assoc.,  1909,  p.  1383. 
Schloffer,   Wien.  klin.   Woch.,  1906,  p.  50. 
Volcker  und  Lichtenberg,  Beitr.  z.  klin.  Chir.,  1907,  p.  1. 
Wagner,  Folia    Urol,,  June,  1907. 
Walker,  Thomson,  Lancet,  Aug.  11.  1906. 


9o4  BIBLIOGRAPHY 

Tumours  of  the  Kidney,  Renal  Pelvis,  and  Ureter 
Garceau,   Tumours  of  the   Kidney.     1909. 
Gregoire,  Presse  Med.,  1905,  p.  49. 

Heresco,    Ann.  des  Mai.  des  Org.   Gen.-Urin.,  1901,  p.  655. 
Israel,  Deuts.  med.   Woch.,  1911,  p.  -"'7. 
Schmieden,  Dcuts.   Zeits.  f.   Chir.,  L902. 

Stoerk,  Beitr.  f.  path.    Aunt.   u.  allgem.  Path,  von  Ziegler,  1908,  p.  393. 
Taddei,  Folia    Urol.,  1908,  pp.  303,  638. 
Walker,   Ann.  of  Surg.,  1897,  p.  549. 
Willis  and  Wilson,    Collected  Papers  of  the  Mayo   Clinic,  1910,  p.  419. 

Cysts  of  the  Kidney 
Gardner,    Intend.    Quart.   Journ.  of  Med.  and  Surg.,  1894,  i.   147. 
Roche,    Ann.  des  Mai.  des  Org.    Gen.-Urin.,  1895,  p.  1139. 
Seiber,  Dents.   Zeits.  f.   Chir.,  1905,  p.  495. 
Stromberg,  Folia  Urol.,  1909,  p.  541. 

Tuberculosis  of  the  Kidney  and  Ureter 
Albarran,    Ann.  des  Mai.  des  Org.  Gen.-Urin.,  1908,  p.  81. 
Brongersma,  /.  Congres  de  V Assoc  Internal.  d'Urol.,  Paris,  1908,  p.  533. 
Casper,  Deuts.  med.   Woch.,  1905,  p.  98. 

Halle  et  Motz,   Ann.  des  Mai.  des  Org.  Gen.-  Urin.,  1906,  i.  162. 
Kronlein,  Folia    Urol.,  1908,  p.  -4.". 
Kiimmel,    Arch.  f.  Kin.    Chir.,  1906,  p.  270. 
Lichtenstein.   Zeits.  i.    Urol.,  1908,  p.  219. 
Walker.  Thomson,  Pract.,  Mav,  1908. 
Zuckerkandl,  Zeits.  f.    Urol.,  1908,  p.  97. 

Tumours  of  the  Suprarenal  Gland 
Ferrier  et  Lecene,  Rev.  de  Chir.,  1906,  p.  325. 
Garceau,   Tumours  of  the  Kidney.     1909. 
Israel,  Dents,  med.   Woch.,  1905,  p.  746. 

Syphilis  and  Bilharziosis  of  the  Kidney 
Delamore.  Gaz.  des  Hop.,  1900,  p.  553. 
Madden,   Bilharziosis.     London.   1907. 
Stoerk,   Wien.  med.   Woch.,  1901. 
Sutherland  and  Thomson  Walker,  Brit.  Med.  Journ.,  April  25,  1903. 

Renal  Calculus 
Bevan  and  Smith,  Surg.,  Gyn.,  and  Obstet.,  1908,  p.  675. 
Brbdel,   Johns   Hopkins   Hosp.  Bull.,  1901,  p.  10. 
Faltin,  Folia    Urol,  1908,  Hefte  3,  4. 
Gage  and  Beal,    Ann.  of  Surg.,  1908,  p.  378, 
Israel,    Arch.  f.  Kin.    Chir.,  1900. 
Kiimmel,   Zeits.  j.    Urol.,  1908,  p.  193. 
Newman,  Lancet,  1909,  p.  8. 

Prolapse  of  the  Ureter 
Kapsammer,   Zeits.  f.    Urol.,  1908,  p.  800. 
Portner,  Monats.  f.   Urol,  1904,  Heft  5 

Injuries  of  the  Ureter 
Alksne,  Folia    Urol.  1908,  p.  280. 

Barnasconi  et  Colombine,    Ann.  des  Mai.  des  Org.  Gen.-Urin.;  1905,  ii.  1361. 
Boari,    II  Policlinico,  July  15,  1899. 
Bovee,   Ann.  of  Surg.,  1900,  p.  165. 
Markoe  and  Wood,    Ann.  of  Surg.,  1899. 
Morris,  Sir  Henry,   Hunterian  Lectures,  1898. 
Poggi.  XIX.    Congres  de   Chir.,  Pari?,  1906,  p.  188. 
Scharpe,    Ann.  of  Surg.,  1906,  p.  687. 


BIBLIOGRAPHY  905 

Fistula  of  the  Ureter 
Boari,   Ann.  des  Mai.  des  Org.  Oiiu-Urin.,  L909,  ii.  L332. 
Payne,  Journ.    Amer.  Med.    Assoc,  1908,  p.  1321. 

Stom;   in    tiii;    I'kkter 
Bloch,  Folia    I'm/.,  April,   1909. 
Jeanbrau,  Des  Calends  dt  V  Ureters.     1009. 
Kolischer  and  Schmidt,  Journ.   Amer.  Med.  Assoc,  Nov.  9,  1001. 
Rigby,    Ann.  of  Surg.,  N'ov.,  1007. 
Walker,  Thomson,   Lancet,  June  17,  1911. 

Examination  of  the  Bladder 
Kapsammer,  Xiercndiagnostik  n.  Xicrenchirurgie.     1007. 
Walker,  Thomson,    R<  rial   Function  in    Urinary  Surgery.     London,  1008. 

Extroversion  of  the  Bladder 
Maydl,   Wien.  med.  Woch.,  1804,  1806,  1800. 
Peters,   Brit.  Med.   Journ.,  1002,  ii.   1538. 
Petersen,  Med.  News,  Aug.  11,  1011. 
Trendelenburg,  Ann.  of  Surg.,  1006,  p.  281. 

Diverticula  of  the  Bladder 
Berry,  Proc  Boy.  Soc.  Med.,  Surg.  Sect.,  1011,  p.  158. 
Young,   Johns   Hopkins  Hosp.  Repts.,  1906,  p.  401. 

Inversion  and  Prolapse  of  the  Bladder 
Hirokawa,  Deuts.   Zeits.  f.   Chir.,  1911,  p.  575. 
Leedham-Green,  Brit.  Med.   Journ.,  1908,  i.  076. 

Injuries  of  the  Bladder 
Dambrin  et  Papin,    Ann.  des  Mai.  des  Org.  Gen.-  Urin.,  1004,  p.  641. 
Goldenberg,  Bcitr.  z.  klin.   Chir.,  1000,  p.  356. 
Morel,    Ann.  des  Mai.  des  Org.   Gen.-  Urin.,  1006,  p.  801. 
Quick,    Ann.  of  Surg.,  1907,  p.  04. 

Syphilis  of  the   Bladder 
Asch,   Zeits.  f.    Urol,  1911,  p.  504. 
von  Engelmann,  Folia   Urol.,  1911,  p.  472. 
Frank,  //.  Deuts.  urol.   Kongress,  Berlin,  1909,  p.  356. 

Actinomycosis  of  the  Bladder 
Ruhrah,    Ann.  of  Surg.,  1899,  p.  417. 
Stanton,   Amer.  Med.,  1906,  p.  401. 

Cystitis 
Halle  et  Motz,    Ann.  des  Mai.  des  Org.   Gen.-  Urin.,  1002,  p.  17, 
Lichtenstein,  Wien.  klin.   Woch.,  1007,  No.  40. 
Newman,  Lancet,  1012,  i.  400. 
Stoerk  und  Zuckerkandl,  Zeits.  f.    Urol.,  1007,  p.  3. 

Tuberculous  Cystitis 
Halle  et  Motz,    Ann.  des  Mai.  des  Ora.   Gen.-  Urin.,  1004.  p.  16_ 
Karo,  Med.  Rec,  Oct.  2,  1000. 
Rovsing,    Arch.  f.  klin.    Chir.,  1007,  p.   1. 
Walker,  Thomson,  Pract.,  May,  1008. 

Tumours  of  the  Bladder 
Casper,  Berl.  klin.   Woch.,  1008,  No.  6. 
Paschikis,  Folia    Urol.,  1008,  ii.  450. 
Rovsing,   Arch.  f.  klin.   Chir.,  1907,  p.  1047. 
Stoerk  und  Zuckerkandl,  Zeits.  f.   Urol.,  1007..  p    1. 


9o6  BIBLIOGRAPHY 

Walker,  Thomson,   Lancet,  Nov.  12,  1910 :    and  //.  Congres  de  V Assoc.  Inlernat. 

d  Urol.,  London,  1911. 
Watson,   Ann.  of  Surg.,  Dec.,  1905. 
Wilder,   Amer.  Journ.  of  Med.  Sci.,  1905,  p.  63. 

Vesical  Calculus 
Histon,  Brit.  Med.   Journ.,  1904,  ii.  833. 
Kasarnowsky,  Folia   Urol,  1909,  p.  469. 
Know,   Zeits.  f.  Oeb.  u.   Gijn,,  1911,  Heft  7. 

Pericystitis 
Schmidt,  Surg.,   Qyh.,  and  Obstet.,  1911,  p.  281. 

Nervous  Diseases  of  the  Bladder 
Bohme,  Munch,  med.  Woch.,  Dec.  15,  1908. 
Corner,   Ann.  of  Surg.,  1901,  p.  456. 
Miiller,  Deuts.  Zeits.  f.  Nervenheilk.,  1901,  p.  86. 
Walker,  Thomson,  Ann.  of  Surg.,  1910,  p.  577;   and  Zeits.  f.   Urol,  1911,  p.  1. 

Congenital  Malformations  of  the  Urethra 
Beck,  N.Y.  Med.  Journ.,  Jan.  29,  1908. 
Bucknall,  Lancet,  .Sept.  28,  1907. 

Dubot,   Ann.  des  Mai.  des  Org.   Gen.-  Urin.,  1902,  No.   1. 
Gutmann,   Zeits.  f.    Urol.,  1910,  p.  575. 
Keith,  Brit.  Med.   Journ.,  1908,  ii.  1805. 

Injuries  and  Rupture  of  the  Urethra 
Legueu,    Ann.  des  Mai.  des  Org.   Gen.-  Urin.,  1907,  ii.  1090. 
Rutherfurd,  Lancet,  Sept.  10,  1904. 
Sczcypiorski,    Ann.  des  Mai.  des  Org.   Gen.-  Urin.,  1907,  ii.   1033. 

Stone  in  the  Urethra 
Fenwick,  Trans.  Path.  Soc,  1890,  vol.  xli. 
Pasteau,    Ann.  des  Mai.  des  Org.  Gen.-  Urin.,  1901,  p.  416. 

Stricture  of  the  Urethra 
Groves,  Hey,  Bristol  Med.-Chir.   Journ.,  1910,  p.  325. 
Rutherfurd,  Lancet,  Sept.  10,  1904. 
Sawamura,  Folia   Urol.,  1910,  iv.  683. 

New  Growths  of  the  Urethra 
Barney,  Boston  Med.  and  Surg.   Journ.,  1907,  p.  790. 
Bonzani,  Folia    Urol.,  1909,  p.  491. 
Hall,   Ann.  of  Surg.,  1904,  p.  375. 
Preiswerk,  Zeits.  f.    Urol.,  1907,  p.  273. 

Tuberculosis  of  the  Urethra  and  Pexlj 
Asch,   Zeits.  f.    Urol.,  1909,  iii.   174. 
Chute,  Boston  Med.  and  Surg.   Journ.,  1903,  p.  361. 
Halle"  et  Motz,   Ann.  des  Mai.  des  Org.   Gen.-  Urin.,  1902,  p.  1464. 
Sawamura,   Folia    Urol.,  1910,  iv.  683. 


THE    MALE   GENITAL  TRACT 
By   RUSSELL   HOWARD,  M.S.,  F.R.G.S. 

THE  PROSTATE 

Anatomy. — The  prostate  is  a  glandular  organ  shaped  like  a  chest- 
nut and  weighing  from  15  to  20  grm.  It  surrounds  the  first  part  of 
the  urethra,  the  base  of  the  bladder  rests  on  it,  and  it  is  situated 
between  the  symphysis  pubis  and  the  rectum. 

The  anterior  aspect  of  the  gland  is  attached  to  the  posterior  surface  of 
the  symphysis  pubis  by 
specialized  bands  of  tlie 
anterior  fibres  of  the  recto- 
vesical fascia  forming  the 
pubo-prostatic  or  anterior 
true  ligaments  of  the  blad- 
der, while  the  lateral  as- 
pects are  covered  with  a 
reflection  from  the  recto- 
vesical fascia  under  which 
a  large  plexus  of  veins 
(the  plexus  of  Santorini) 
is  found.  The  posterior 
aspect  is  attached  to  the 
rectum  by  dense  fibrous 
connective  tissue  in  which 
no  large  vessels  are  found. 

Many  of  the  fibres  of 
the  levator  ani  muscle  end 


Fig.  555. — Section  of  normal  prostate,  show- 
ing the  prostatic  plexus  of  veins  and  the 
capsule. 


on  the  prostate,  which  thus  lies  outside  the  pelvis  but  in  the  tissue  that 
forms  the  pelvic  diaphragm. 

The  prostatic  urethra  is  1£  in.  long,  crescentic  on  section,  and  pene- 
trates the  prostate  in  such  a  way  that  a  large  segment  of  the  gland  lies 
below  and  a  small  one  above  it.  The  common  ejaculatory  ducts  pierce 
the  prostate,  and,  like  the  sinus  pocularis  and  prostatic  glands,  open  into  the 
prostatic  urethra. 

The  arteries  of  the  prostate  are  derived  from  the  interior  vesical  artery ; 
and  the  veins,  which  form  a  large  plexus  round  the  gland,  enter  the  dorsal 
vein  of  the  penis  and  the  veins  of  the  urethra.     (Fig.  555.) 


907 


908  THE   PROSTATE 

ACUTE   PROSTATITIS 

Acute  prostatitis  in  the  vast  majority  of  cases  follows  gonorrhoea! 
urethritis  or  urethritis  due  to  instrumentation  of  the  urethra,  but  it 
may  occur  occasionally  in  the  course  of  one  of  the  infectious  fevers. 
The  gonococcus  enters  the  prostate  through  the  prostatic  ducts  and 
initiates  an  acute  inflammation,  ending  either  in  resolution,  chronic 
prostatitis,  or  suppuration.     (See  Vol.  I.,  pp.  808,  841.) 

CHRONIC    PROSTATITIS 

Chronic  inflammation  of  the  prostate  is  most  frequently  secondary 
to  a  chronic  urethritis,  usually  gonococcal,  but  may  follow  an  acute 
prostatitis.  The  condition  is  a  very  common  sequel  to  gonorrhoea, 
and  has  far-reaching  consequences.     The  morbid    anatomy  shows  a 

chronic  suppuration  occurring 
in  the  ducts  of  the  prostate 
with  interstitial  fibrosis,  the  pus 
escaping  into  the  urethra  and 
appearing  in  the  urine  as  comma- 
shaped  white  threads.  It  is  one 
of  the  causes  of  gleet. 

The  condition  is  discussed  in 
Vol.  I.,  p.  842. 

PROSTATIC    CALCULI 
ing  the  corpora  amylacea.  I*  is  important  to  distinguish 

two  separate  conditions  which 
have  been  described  under  this  term.  They  are  (a)  calculi  in  the  pros- 
tatic urethra,  (6)  calculi  in  the  prostate.  The  first  are  formed  either 
in  the  kidney,  the  bladder,  or  locally  in  the  prostatic  urethra,  and. 
becoming  impacted,  cause  difficulty  of  micturition.  They  will  not  be 
further  discussed  here.  Calculi  of  the  second  variety,  the  true  pros- 
tatic calculi,  are  formed  in  the  prostate  itself.  In  every  adult  prostate 
tmall  bodies  known  as  corpora  amylacea  are  found  (Fig.  556), 
which  consist  of  inspissated  secretion,  epithelial  cells,  and  lecithin. 
They  are  multiple,  and  of  a  colour  varying  from  light  grey  to  black. 
These  bodies  are  scarcely  pathological,  but  become  so  when  by  in- 
filtration with  lime  salts  they  form  prostatic  calculi  (Fig.  557). 
Stones  in  the  prostate  are  therefore  usually  multiple,  over  a  hun- 
dred having  been  met  with  in  some  cases,  and  are  usually  small, 
but  they  may  weigh  as  much  as  120  grm.  They  consist  of  phos- 
phate, oxalate,  and  carbonate  of  lime  round  an  organic  nucleus, 
and  so  give  a  good  shadow  with  the  X-rays. 

Symptoms. — Calculi  may  exist  for  years  in  the  prostate,  and 
only  be  discovered  on  autopsy.     In  some  cases  they  are  passed  per 


PROSTATIC   CALCULI 


909 


urethra,  in  without  other  symptoms.  When  symptoms  are  present 
they  are  those  of  cystitis  of  the  base  of  the  bladder,  viz.  pain,  diffi- 
culty and  frequency  of  micturition.  The  symptoms  arise  when  the 
calculus  protrudes  into  the  prostatic  urethra  either  through  one  of 
the  ducts  or  by  ulceration  of  the  mucous  membrane.  Hematuria 
may  occur,  but  is  usually  slight,  and  urethral  discharge  may  be 
present.  Suppuration  may  take  place  round  the  calculi  and  lead 
to  formation  of  an  abscess,  which  may  burst  into  the  urethra,  the 
perineum,  or  the  rectum. 

The  diagnosis  is  made  by — (1)  Feeling  the  stones  per  rectum, 
if  they  are  large  enough.  In 
some  cases  the  stones  may 
be  felt  to  grate  on  one 
another.  (2)  Feeling  the 
stones  in  the  urethra  by  the 
passage  of  a  sound.  The 
grating  characteristic  of  a 
calculus  is  always  felt  in  the 
same  place  just  as  the  sound 
enters  the  bladder.  In  some 
cases  combined  rectal  and 
urethral  examination  may 
lead  to  a  correct  diagnosis. 
{3)  Radiography,  only  a 
positive  result  being  of 
value. 

Treatment. — In  cases 
of  accidental  discovery  of  prostatic  calculi  no  treatment  is  necessary, 
but  if  symptoms  are  present  the  prostate  should  be  incised  from  the 
perineum  and  all  the  stones  removed.  Calculi  in  the  prostate  may 
also  be  reached  through  the  bladder.  This  viscus  is  opened  by  the 
suprapubic  route,  the  prostate  incised,  and  the  stones  removed. 

Abscesses  should  be  treated  by  perineal  incision,  removal  of  the 
calculi,  and  drainage. 

TUBERCULOSIS 

As  in  tuberculosis  of  the  other  parts  of  the  genito-urinary  tract, 
tuberculosis  of  the  prostate  is  most  commonly  seen  in  young  adults 
and  in  those  who  are  disposed  to  the  disease  by  heredity.  Chronic 
inflammation  of  the  prostate  due  to  infection  by  the  gonococcus  is 
another  very  important  predisposing  condition,  and  one  on  which 
too  little  stress  has  been  laid.  The  disease  in  the  prostate  is  frequently 
associated  with  tuberculosis  of  the  kidney,  bladder,  vesiculae,  and 
testis,  and  it  is  often  difficult  in  a  given  case  to  distinguish  the  primary 


Fig.  557. — Prostate  with  prostatic 
calculi  in  situ. 


9io  THE    PROSTATE 

focus.  The  pathological  anatomy  of  the  disease  does  not  differ  from 
that  of  tuberculosis  elsewhere.  The  tuberculous  process  usually  com- 
mences at  the  periphery  of  the  gland,  and  then  invades  the  centre  ;  the 
tubercles  coalesce  to  form  soft  caseous  areas  in  the  gland,  which  may 
burst  into  the  urethra,  the  perineum,  the  bladder,  or  the  rectum. 

Symptoms. — Tuberculosis  of  the  prostate  may  be  latent  for 
months  or  years,  and  is  frequently  discovered  during  a  routine  examin- 
ation of  the  prostate  and  vesiculse  in  the  investigation  of  a  case  of 
testicular,  renal,  or  vesical  tuberculosis.  Even  when  symptoms  are 
present  they  are  not  pathognomonic,  for  they  closely  resemble  those 
of  any  form  of  inflammation  of  the  base  of  the  bladder. 

The  symptoms  are  pain,  frequency,  and  difficulty  of  micturition, 
unrelieved  by  treatment ;  a  burning,  aching  pain  in  the  perineum  and 
round  the  anus,  and  the  presence  of  blood  in  the  urine  and  semen. 
The  hsematuria  is  usually  seen  at  the  end  of  micturition,  and  is  slight, 
but  is  increased  by  instrumentation  of  the  urethra.  The  hemospermia  is 
also  slight,  and  may  be  absent.  A  urethral  discharge  may  be  present, 
but  its  diagnostic  importance  is  minimized  by  the  difficulty  of  establish- 
ing its  prostatic  origin  and  of  demonstrating  tubercle  bacilli  in  it. 

Diagnosis. — This  depends  on  rectal  examination  combined  with 
evidence  of  tuberculosis  elsewhere  in  the  body,  but  especially  in  the 
genito-urinary  tract.  On  examination  the  prostate  is  found  to  be 
somewhat  enlarged  and  feels  nodular,  the  nodules  being  small  and 
isolated  and  more  uneven  than  in  any  other  disease.  The  gland  is 
tender ;  in  advanced  cases  fluctuation  is  present,  and  the  seminal 
vesicles  can  frequently  be  felt  to  be  affected. 

Tuberculosis  of  the  prostate  may  not  be  suspected  until  a  fluctuat- 
ing swelling  is  found  in  the  perineum  or  bulging  the  anterior  rectal  wall. 

Examination  of  the  urethra  by  the  sound  and  endoscope,  or  exam- 
ination of  the  bladder  by  the  cystoscope,  is  of  little  value  in  the  diag- 
nosis. These  examinations  are  unnecessary,  and  may  result  in  severe 
hematuria  or  cystitis. 

The  prognosis,  as  in  all  other  forms  of  genito-urinary  tuberculosis, 
is  not  very  favourable,  but  cure  may  result  if  other  parts  of  the  tract 
are  not  seriously  involved. 

Treatment. — The  treatment  consists,  for  the  most  part,  of 
general  hygienic  measures  and  vaccine  inoculation.  All  local  applica- 
tions to  the  deep  urethra  are  to  be  avoided,  as  they  can  do  no  good 
to  the  tuberculous  process  in  the  substance  of  the  gland. 

Catheterization  for  the  relief  of  pain  and  difficulty  of  micturition 
is  useless  as  a  lasting  resource,  and  continuous  catheterization  cannot 
be  borne.  When  the  pain  and  urgency  of  micturition  become  intoler- 
able, the  bladder  should  be  opened  and  permanently  drained  by  a 
suprapubic  incision. 


CHRONIC   ENLARGEMEN  I  911 

Radical  treatment,  consisting  of  removal  of  the  entire  prostate 
with  the  vesicular  seminales,  has  been  attempted  with  some  measure 
of  success,  but  is  only  appropriate  in  a  minority  of  cases-^those  in 
which  tuberculosis  is  no1  advanced  in  other  organs,  but  is  primarily 
localized  to  the  prostate. 

If  an  abscess  forms,  it  should  be  opened  from  the  perineum,  the 
walls  thoroughly  scraped  to  eradicate  the  disease,  and  the  cavity 
injected  with  iodoform  emulsion.  Fistulae  should  be  treated  by 
thorough  curetting.  The  prognosis  of  this  operation  is  not  good, 
fistulae  usually  remaining. 

CHROXIC    ENLARGEMENT 

Pathology. — The  pathology  of  the  increase  in  volume  and  altera- 
tion in  shape  of  the  prostate  that  occurs  so  frequently  after  middle 
life  is  not  finally  settled,  so  that  the  term  chronic  enlargement  is  to 
be  preferred  to  another  term  which  would  imply  a  more  exact  patho- 
logical condition.  From  histological  examination  alone  authors  have 
differentiated  (a)  a  diffuse  fibro-myomatous  overgrowth  (myomatosis), 
(b)  a  form  with  multiple  localized  fibro-myomas,  (c)  a  diffuse  adeno- 
matous overgrowth,  (d)  a  form  with  localized  adenomas  ;  but  there  is 
much  evidence  that  these  variations  are  merely  stages  of  the  same 
pathological  change. 

Etiology. — The  cause  of  chronic  enlargement  of  the  prostate  is 
quite  unknown,  but  the  following  theories  have  been  held  : — 

1.  The  disease  is  a  new  formation  either  of  fibro-myomas,  similar 
to  those  in  the  uterus,  or  of  fibro-adenomas. 

2.  It  is  a  part  of  a  general  arterio-sclerosis,  or  of  a  localized  arterio- 
sclerosis affecting  the  urinary  organs. 

3.  It  is  an  inflammatory  hyperplasia  of  the  elements  of  the  gland 
due  to  alcoholism,  sexual  excess,  constipation,  sedentary  life,  etc. 

4.  It  is  a  terminal  result  of  chronic  gonorrhceal  inflammation  of 
the  gland. 

But  none  of  these  theories  is  satisfactory,  and  it  is  best  at  present 
to  consider  the  condition  as  a  chronic  enlargement  of  the  prostate 
occurring  for  unknown  reasons  in  men  after  the  age  of  50.  Cases, 
however,  have  been  known  before  this  age. 

Enlargement  of  the  prostate  is  of  no  more  intrinsic  importance 
than  a  lipoma  of  the  shoulder ;  its  seriousness  depends  upon  the  inter- 
ference with  the  act  of  micturition,  due  to  the  position  of  the  gland  at 
the  outlet  of  the  bladder. 

Condition  of  the  prostate. — The  prostate,  if  normal,  weighs 
about  20  grm.,  but  when  chronically  enlarged  has  been  found  to 
weigh  as  much  as  250  grm.,  or  more ;  it  may  be  enlarged  as  a  whole 
or  in  parts,  and  the  enlargement  may  be  symmetrical  or  asymmetrical. 


912 


THE   PROSTATE 


If  enlarged  as  a  whole  it  becomes  more  spherical,  and  the  groove 
between  the  lateral  lobes  is  obliterated.  The  enlargement  may  be 
slight  and  hard,  or  very  great  and  soft.  In  partial  enlargements 
the  middle  lobe  (i.e.  that  part  between  the  mucous  membrane  of  the 
bladder  and  the  common  ejaculatory  ducts)  is  the  part  usually  affected, 
and  projects  into  the  bladder  as  a  spherical  mass  or  as  a  collar  sur- 
rounding the  orifice  of  the  urethra.  Such  an  enlargement  of  the  middle 
lobe  cannot  be  felt  per  rectum,  although  it  may  attain  the  size  of  a 
large  walnut  and  block  the  entrance  of  the  urethra.     The  anterior 

commissure  is  rarely  affected. 
(Fig.  558.) 

Results,  (a)  Effects  on 
the  urethra. — The  enlarge- 
ment of  the  prostate  takes 
place  in  an  upward  direction, 
owing  to  the  resistance  of  the 
triangular  ligament,  and  car- 
ries the  base  of  the  bladder 
with  it.  This  produces  a 
lengthening  of  the  prostatic 
urethra,  so  that  an  ordinary 
catheter  may  not  be  able  to 
reach  the  bladder.  The  total 
urethra  may  increase  in  length 
from  the  normal  8  in.  to  12  in. 
The  calibre  of  the  urethra 
may  be  altered  in  two  ways  : 
either  it  may  be  narrowed  by 
Fig.  558.— An  enlarged  prostate  after  the  pressure  inwards  of  the 
removal    by   the   suprapubic   route.        ,    r   ,    .  ,    ,  ,  .. 

The    median    lobe     is     particularly    enlargec*    iateral    10Des>    or.  1V 
affected.  may    t>e    widened     by    bemg 

stretched  over  the  mass ;  the 
latter  is  the  more  common.  Deviation  of  the  urethra  may  also  occur 
from  excessive  enlargement  of  one  or  other  lateral  lobes.  The  shape 
of  the  prostatic  urethra  is  frequently  altered  by  enlargement  of  the 
middle  lobe,  so  that  it  is  more  curved  than  usual  and  requires  the 
use  of  a  catheter  with  a  special  bend. 

(6)  Effects  on  the  bladder. — "With  the  increasing  difficulty 
in  expelling  the  urine,  the  muscular  wall  of  the  bladder  becomes  hyper- 
trophied ;  but  this  change  soon  reaches  its  limit  in  elderly  men,  and 
is  followed  by  dilatation  of  the  bladder,  fasciculation  and  vesiculation, 
with  fibrosis  of  the  muscle  bundles.  The  projection  into  the  bladder 
of  the  enlarged  prostate  causes  the  orifice  of  the  urethra  to  be  no 
longer  the  lowest  part  of  the  bladder,  and  there  is  the  formation  of 


CHRONIC    ENLARGEMENT 


913 


■  steadily  enlarging  periprostatic  pouch  behind  the  enlarged  middle 
lobe.     (Fig.  559.) 

(c)  Effects   on    ureters   and    kidneys — The  effects  on  these 
Mm.  1  urea  are  similar  to  those  following  other  causes  of  urethral  ol> 
tion,  e.g.  stricture.     The  lumen  of  the  ureter  becomes  dilated,  and 
its  muscular  c< 

atrophied,  till  the 
tube  may  reach 
the  size  of  a  piece 
of  small  intestine. 
The  pelvis  of  the 
kidney  becomes 
dilated,  and  there 
is  an  interstitial 
fibrosis  of  tin- 
kidney  which  de- 
stroys the  secre- 
tory tubules  and 
leads  to  renal  in- 
sufficiency. 

(d)  I  nflam- 
matory  effects. 
— Sooner  or  later 
a  cystitis  de- 
velops, either 
from  direct  infec- 
tion by  instru- 
mentation or  by 
infection  from  the 
bowel,,  and  there 
will  follow  ureter- 
itis, pyelitis,  and 
pyelonephritis. 

(e)  Effects 
on  the  circula- 
tion.—The  veins 
of  the  peripros- 
tatic plexus,  with 
which  the  dorsal  veins  of  the  penis  communicate,  become  dilated  and 
varicose.    Rupture  of  one  of  these  may  even  lead  to  profuse  hsematuria. 

(0  Effects  on  the  sexual  organs. — The  common  ejaculatory 
ducts  which  pass  through  the  prostate  may  be  distorted  and  com- 
pressed so  that  semen  can  no  longer  pass  along  them.  This  will  lead 
to  dilatation  of  the  vesiculse  seminales  and  to  aspermia. 


Fig.  559. — Bladder  laid  open,  showing  the  obstruc- 
tion caused  by  enlargement  of  the  prostate.  A 
bristle  is  seen  in  each  ureter  and  a  stylet  in  the 
urethra. 


yM  THE   PROSTATE 

(g)  Effects  on  the  act  of  micturition. — The  increasing  obstruc- 
tion at  the  orifice  of  the  urethra  leads  to  increasing  difficulty  of  mic- 
turition, the  chief  difficulty  being  experienced  in  starting  the  act. 
With  enlargement  of  the  middle  lobe,  straining  to  pass  urine  drives 
the  lobe  still  farther  into  the  orifice  of  the  urethra,  and  the  patient 
learns  that  straining  is  futile.  The  absence  of  effort  and  the  weakening 
of  the  bladder  wall  lead  to  diminished  force  of  the  stream,  which  is 
hardly  projected  beyond  the  feet.  The  bladder  is  not  completely 
emptied  by  the  act,  and  urine  will  accumulate  (residual  urine). 

Symptoms. — The  patient  in  the  early  stage  of  enlargement  com- 
plains of  increasing  difficulty  and  also  of  frequency  of  micturition. 
The  difficulty  is  most  marked  at  the  commencement  of  the  act,  and 
the  patient  finds  that  micturition  is  most  easily  performed  by  waiting 
without  straining.  Frequency  is  often  first  noticed  at  night,  the 
patient  rising  two  or  three  times  to  empty  the  bladder ;  the  amount 
of  urine  voided  at  night  is  increased  (nocturnal  polyuria).  There  is 
loss  of  projection  of  the  stream,  and  the  patient  frequently  cannot 
micturate  in  the  recumbent  position.  The  difficulty  of  micturition  is 
increased  by  cold,  alcoholic  or  venereal  excesses,  constipation,  or  by 
holding  the  urine  longer  than  is  desirable.  Increased  sexual  excite- 
ment and  persistent  erections,  which  may  induce  acts  of  impropriety, 
are  common.  The  difficulty  and  frequency  of  micturition  may  steadily 
increase  until  the  bladder  becomes  constantly  distended,  and  incon- 
tinence with  overflow  results,  but  any  of  the  following  complications 
may  supervene  and  alter  the  clinical  picture  : — 

1.  Complete  retention  of  urine.  This  is  due  to  congestion  of  the 
prostatic  plexus  of  veins  and  the  urethral  mucous  membrane,  induced 
by  cold,  by  venereal  excess,  or  more  frequently,  by  prolonged  holding  of 
the  urine,  such  as  may  occur  on  long  railway  journeys  or  at  public 
meetings.  This  complication  may  be  the  first  serious  intimation  to 
the  patient  that  he  has  prostatic  enlargement. 

2.  Severe  haemorrhage  from  rupture  of  a  prostatic  vein. 

3.  Cystitis,  causing  pain  on  micturition,  frequency,  and  pyuria. 

4.  Calculus  in  the  bladder,  causing  pain  on  micturition  and 
haematuria. 

5.  Prostatic  abscess — a  rare  complication. 

Effects  on  the  general  health.— The  general  health  may 
remain  good  for  years,  but  with  increasing  frequency  and  difficulty 
there  is  impairment  due  to  pain  and  loss  of  sleep.  As  the  bladder 
becomes  distended  and  the  effects  of  back  pressure  on  the  kidneys 
are  felt,  the  patient  suffers  from  headaches,  thirst,  polyuria,  and 
anorexia,  and  there  is  loss  of  flesh  and  strength.  These  effects 
are  more  marked  if  sepsis  is  added  to  the  mechanical  effects  of 
the  enlarged  prostate. 


CHRONIC    ENLARGEMENT 

Examination.  -Examination  per  rectum  may  reveal  a  large  soft 
prostate  pressing  backwards  into  t  be  rectum,  or  a  firm,  slightly  enlarged 
prostate.  In  both  cases  tin-  enlargement  is  smooth  and  the  mucous 
membrane  of  the  rectum  moves  easily  over  it.  One  or  other  lateral 
lobe  may  be  chiefly  enlarged,  but  the  condition  of  the  middle  lobe 
cannot    be  examined  through  the  rectum. 

Examination  of  the  urethra  with  a  catheter  reveals  an  obstruction 
to  the  passage  of  the  instrument  at  the  entrance  to  the  bladder.  The 
urethra  is  found  to  be  lengthened,  and  the  curve  of  the  instrument 
has  to  be  altered  to  allow  it  to  slip  past  the  obstruction.  The  catheter 
is  not  gripped  on  removal,  as  it  is  by  a  stricture. 

The  endoscope  is  not  of  much  value  in  examination  of  the  enlarged 
prostate,  but  the  cystoscope  will  permit  examination  of  an  enlarged 
middle  lobe,  besides  showing  the  condition  of  the  bladder  walls,  the 
mouths  of  the  ureters,  and  the  presence  or  absence  of  pouches  and 
calculi. 

Residual  urine  is  examined  for  by  making  the  patient  micturate 
until  he  thinks  the  bladder  is  emptied,  and  then  passing  a  catheter ; 
but  several  examinations  are  necessary,  as  the  condition  fluctuates. 

The  condition  of  the  kidneys  can  be  ascertained  by  a  careful  analysis 
of  a  twenty-four  hours'  specimen  of  urine,  by  examining  the  blood 
pressure,  the  hsemo-renal  index  and  the  electrical  conductivity  of 
the  urine.     The  urine  should  also  be  examined  for  pus  and  bacteria. 

General  treatment. — The  patient  should  carefully  avoid  all 
causes  of  prostatic  congestion,  such  as  alcoholic  and  venereal  excess, 
constipation,  bicycling,  horseback  riding,  the  use  of  highly  spiced  food, 
and  the  prolonged  holding  of  the  urine.  He  should  avoid  late  meals, 
drink  freely  of  non-alcoholic  fluid,  and  take  as  much  exercise  as  his 
general  condition  will  allow.  By  following  the  rules  of  a  regular, 
simple  life,  a  prostatic  patient  may  live  for  years  in  comfort,  and  avoid 
both  catheterization  and  operation. 

Catheterization — This  should  only  be  resorted  to  when  abso- 
lutely necessary,  and  then  under  strict  aseptic  precautions.  For  acute 
retention  the  catheter  must  be  passed  (see  later) ;  for  chronic  retention 
also  this  instrument  must  be  employed,  but  the  frequency  of  its  use 
varies  considerably.  It  may  only  be  necessary  to  empty  the  bladder 
at  long  intervals  (months  intervening),  when  some  slight  prostatic  con- 
gestion is  present,  but  the  frequency  with  which  catheterization  is 
required  generally  increases.  A  patient  with  a  large  bladder  rarely 
has  to  pass  the  catheter  more  than  twice  a  day,  but  if  the  bladder 
be  small  and  spasm  of  the  muscle  be  present,  more  frequent  catheter- 
ization is  necessary.  "  Catheter  life,"  with  the  infrequent  or  regular 
passage  of  a  catheter,  may  be  lived  for  years  with  comfort,  and  is 
consistent  with  great  bodily  and  mental  activity. 


916  THE    PROSTATE 

The  catheters  (which,  of  course,  must  be  carefully  sterilized)  should 
be  soft  and  large-bored,  the  coude  or  bi-coude  being  the  most  con- 
venient shape.  Metal  catheters  should  only  be  used  if  soft  ones  cannot 
be  passed,  and  then  only  by  the  surgeon.  A  gum-elastic  catheter,  of 
which  the  curve  can  be  altered  whilst  in  the  urethra  by  partially  with- 
drawing the  stilette,  is  often  serviceable. 

Permanent  catheterization  is  indicated  if  with  c}rstitis  catheteriza- 
tion is  difficult,  painful,  or  associated  with  haemorrhage.  A  soft,  self- 
retaining  catheter,  such  as  Casper's,  should  be  passed,  and,  if  the 
bladder  is  washed  out  twice  daily,  may  be  retained  for  a  month  and 
then  changed.  At  first  the  patient  should  be  kept  in  bed,  but  later  he 
may  be  allowed  up  with  a  suitable  apparatus ;  he  should  empty  the 
bladder  every  two  or  three  hours.  A  urethritis  is  always  caused  at  first, 
but  this  soon  ceases,  and  the  catheter  may  be  worn  with  comfort. 

Cystitis  should  be  treated  by  the  administration  of  urinary  anti- 
septics, and  by  washing  out  the  bladder ;  and  strict  asepsis  is 
essential  in  all  instrumentation. 

Operative  measures. — The  modern  operative  treatment  of 
the  chronically  enlarged  prostate  consists  of  removal  of  the  organ, 
either  by  the  suprapubic  or  the  perineal  route.  Whether  the  prostate 
is  removed  in  its  entirety  from  its  sheath,  or  whether  fibro-myomatous 
or  adenomatous  growths  are  shelled  out  from  the  prostate,  is  a  matter 
of  dispute,  and  is  of  little  interest  from  the  clinical  point  of  view,  but 
the  question  of  the  selection  of  cases  suitable  for  this  operation  is  of 
vital  importance. 

There  can  be  no  doubt  that  some  patients  with  prostatic  enlarge- 
ment live  for  years  in  comfort  by  careful  attention  to  their  mode  of 
life  and  the  occasional  passing  of  a  catheter,  but,  on  the  other  hand, 
many  cases  do  badly.  Difficulty  in  passing  a  catheter,  haemorrhage, 
cystitis,  attacks  of  acute  retention,  and  the  formation  of  calculi  are 
common,  and  lead  to  much  misery  ;  while  the  back-pressure  effects 
on  the  kidneys  with  ascending  pyelitis  tend  to  shorten  life,  and  render 
some  radical  treatment  necessary. 

Complete  prostatectomy  in  the  majority  of  cases  relieves  the 
patient  of  all  his  symptoms  and  is  a  most  successful  operation,  but 
it  is  not  without  serious  risk  of  death  from  shock  or  haemorrhage,  and 
important  sequelae  and  complications  may  deduct  from  the  value  of 
the  result.  It  must  also  be  remembered  that  in  some  cases — 10  per- 
cent., according  to  some  observers — the  diagnosis  should  be  carcinoma 
of  the  prostate,  and  the  early  removal  may  possibly  result  in  cure, 
winch  is  most  unlikely  if  the  patient  is  left  till  the  diagnosis  is  certain. 
The  condition  of  the  prostate  must  also  be  considered,  the  large  soft 
prostate  being  much  more  readily  removed,  with  less  fear  of  com- 
plications, than  the  hard  small  prostate. 


COMPLETE   PROSTATECTOMY  n; 

Above  all,  the  general  condition  of  the  patient  inu-i  |be  tajken  into 
account,  and  more  especially  the  state  of  the  kidneys,  as  shown  by  the 
patient's  symptoms  and  a  careful  analysis  of  his  urine.  A  weak  heart, 
atheroma  of  the  vessels,  urine  of  persistent  low  specific  gravity  contain- 
ing albumin  and  of  low  molecular  concentration,  contra-indicate  the 
operation,  as  do  wasting,  thirst,  headache,  polyuria,  and  a  low  hsemo- 
renal  index.  Pyuria  from  cystitis,  or  unilateral  pyelitis,  is  not  a  barrier 
to  operation  if  the  urine  is  of  high  specific  gravity,  many  cases  of 
cystitis  clearing  up  after  the  operation. 

To  sum  up,  complete  prostatectomy  is  indicated  if  a  patient  with 
a  chronically  enlarged  prostate  has  to  pass  a  catheter  frequently  or 
passes  it  with  difficulty,  if  the  use  of  the  instrument  causes  pain  and 
hematuria,  if  cystitis  supervene  or  a  calculus  form  in  the  bladder, 
or  if  attacks  of  acute  retention  are  common,  provided  that  the 
general  condition  is  good  and  the  kidneys  are  shown  to  be  doing  their 
work  well.  The  operation  is  more  especially  indicated  if  the  prostate 
is  large  and  soft.  The  question  of  the  route,  suprapubic  or  perineal, 
to  be  adopted  is  not  yet  settled,  but  the  balance  of  evidence  at 
present  is  in  favour  of  suprapubic  prostatectomy,  and  most  surgeons 
adopt  this  route  for  all  their  cases.  It  is  the  easier  operation,  and 
permits  a  more  thorough  exposure  of  the  bladder ;  its  great  dis- 
advantage, difficulty  of  drainage,  seldom  arises. 

The  operation  consists  in  opening  the  bladder  by  an  incision  above 
the  pubis  after  the  viscus  has  been  distended  with  fluid,  incising 
the  mucous  membrane  over  the  prostate,  and  then  enucleating  the 
organ  with  the  fingers,  aided  by  the  fingers  of  the  other  hand  in  the 
rectum  pushing  the  prostate  upwards  and  forwards.  The  prostatic 
urethra  and  the  common  ejaculatory  ducts  are  usually  torn  across. 
After  the  prostate  has  been  removed,  haemorrhage  is  stopped  by  sponge 
pressure,  and  the  bladder  drained  by  a  large  tube.  The  after-treatment 
consists  in  washing  the  bladder  out  daily,  the  tube  being  removed  on 
the  third  day.  The  suprapubic  wound  should  be  closed  at  the  end 
of  the  third  week. 

Perineal  prostatectomy. — This  operation  may  be  performed  in  many 
ways,  and  the  primary  incision  in  the  perineum  may  be  either  a  median 
longitudinal  or  a  transverse  one.  In  the  median  perineal  incision  the 
membranous  urethra  is  opened,  the  prostatic  urethra  dilated,  and  a 
retractor  passed  into  the  bladder,  so  that  when  it  is  pulled  upon  the 
prostate  is  drawn  into  the  wound ;  the  fibrous  sheath  of  the  prostate 
is  then  incised,  and  the  gland  enucleated  with  the  finger  in  one  or 
more  pieces.  The  bladder  is  drained  by  a  tube,  and  the  cavity,  left 
by  removal  of  the  prostate,  packed  with  gauze.  During  healing  a 
bougie  must  be  passed  at  regular  intervals  to  maintain  the  patency 
of  the  urethra. 


9iS  THE   PROSTATE 

Complications  of  complete  prostatectomy.—  Hemorrhage 
may  be  severe,  but  will  usually  yield  to  sponge-pressure  and  adrenalin. 
It  may,  however,  be  necessary  to  pack  the  cavity  left  by  removal  of 
the  prostate. 

Sepsis. — Acute  epididymo-orchitis  may  occur,  especially  if  cystitis 
have  existed  before  the  operation.  The  condition  frequently  ends 
in  suppuration.  Ascending  pyelitis  may  also  occur.  Cellulitis  of 
the  pelvic  tissue  is  an  occasional  sequela.  Stricture,  incontinence  of 
urine,  and  suprapubic  fistula  may  all  follow  the  operation. 

The  sexual  power  may  be  lost,  but  this  is  more  common  after  the 
perineal  operation  than  after  the  suprapubic.  Power  of  erection 
may  remain,  but  without  ejaculation  of  semen.  In  some  cases,  lost 
sexual  power  may  be  regained. 

Urcemia  with  suppression  of  urine  may  speedily  follow  operation. 

Calculi  may  form  in  the  pouch  left  after  removal  of  the  prostate. 

Treatment  of  acute  retention  of  urine  due  to  en- 
larged prostate. — A  full  dose  of  urotropine  should  be  given,  and 
an  attempt  made  to  empty  the  bladder  by  catheterization.  If  this 
succeeds,  the  bladder  must  be  emptied  regularly  until  the  power  of 
spontaneous  micturition  is  regained.  A  second  attack  of  retention 
should  not  be  allowed  to  occur.  If  regular  catheterization  is  impos- 
sible, a  catheter  should  be  tied  into  the  bladder  for  a  day  or  two. 

If  catheterization  fails,  the  bladder  should  be  aspirated  above  the 
pubes,  and  then  another  attempt  made  to  pass  and  tie  in  a  catheter. 
If,  after  two  or  three  suprapubic  aspirations,  attempts  to  catheterize 
fail,  the  bladder  should  be  drained  through  a  suprapubic  incision,  and 
a  day  or  two  later  the  prostate  removed  by  this  route. 

NEW   GROWTHS 

Benign  growths  of  the  prostate  only  exist  as  the  adenomas  and  fibro- 
myomas  of  chronic  enlargement,  and  have  been  considered  under  that 
heading  (p.  913). 

Malignant  growths  of  the  prostate  consist  of  sarcoma  and  car- 
cinoma, of  which  the  latter  is  by  far  the  more  common. 

Sarcoma1 

Sarcoma  of  the  prostate  is  rare,  but  it  occurs  at  all  ages,  even 
sometimes  in  infants  ;    it  is  invariably  primary. 

Symptoms. — There  is  an  increasing  difficulty  in  passing  urine, 
with  more  or  less  sudden  complete  retention.  Occasionally  hematuria 
and  pyuria  are  present,  and  fragments  of  growth  may  be  passed  per 
urethram.  On  rectal  examination  the  growth  is  felt  projecting 
backwards  into  the  rectum  as  a  large,  firm  mass,  over  which  the  mucous 
1  .See  also  Vol.  I.,  p.  509. 


CARCINOMA    OF  THE    PROSTATK  919 

membrane  does  not  move  freely.  Involvement  of  the  pelvic  glands  is 
late,  but  metastasis  in  the  lungs  and  other  organs  is  common,  the 
disease  being  invariably  fatal. 

Treatment. — This  is  similar  to  the  palliative  treatment  of  car- 
cinoma of  the  prostate  (p.  923).  Attempts  at  removal  can  be  made, 
but  are  usually  followed  by  rapid  local  recurrence. 

Carcinoma1  (Fig.  560) 

Etiology. — In  the  prostate,  as  in  other  parts  of  the  body,  the 
cause  of  carcinoma  is  unknown.  It  has  been  stated  that  malignant 
disease  not  infrequently  commences  as  chronic  enlargement,  but 
proof  of  this  is  wanting,  and  it  is  more  likely  that  the  cases  were 
carcinomatous  from  the  first.  Chronic  gonorrhceal  inflammation  has 
also  been  assigned  as  a  cause,  but  on  insufficient  evidence. 

Pathologically,  the  disease  can  be  divided  into  soft  (medullary) 
and  hard  (scirrhus)  types,  according  to  the  amount  of  fibrous  tissue 
in  the  growth  ;    but  of  more  importance  is  the  clinical  division  into — 
(a)  Growths  which  for  a  long  time  resemble  innocent  enlarge- 
ments, and  are  frequently  removed  under  that  idea,  the 
diagnosis  being  established    by   the   microscope   and    the 
after-history.  ■ 

(6)  Growths   which,  having  rapidly  infiltrated  the   surrounding 
tissue,  f ungate  into  the  bladder  and  rectum  and  involve 
the  pelvic  glands  early,  so  that  the  pelvis  soon  becomes 
filled   with   a    carcinomatous  mass.     These   cases  are  the 
diffuse  prostato-pelvic  carcinomas  of  Guyon. 
(c)  A  rare  form  of  growth  which  is  followed  by  general  carcino- 
matous invasion  of  bone,  the  primary  growth  in  the  pros- 
tate   being   small   and   often    difficult  to   discover.      The 
secondary  growths  occur  in  the  bone  marrow,  especially  of 
the  vertebra?,  of  the  lower  end  of  the  femur  and  of  the 
humerus,  and  gradually  destroy  the  bone,  leading,  in  some 
cases,    to    multiple     spontaneous    fractures.       Secondary 
growths   in    internal    organs   are    rare,   but  carcinoma   of 
the  prostate  in  man  is  sometimes  associated  with  general 
carcinomatosis. 
Secondary  carcinoma  of  the  prostate  is  rare,  and  it  is  unusual 
for  bladder  growths  to  invade  the  prostate,  although  invasion  of  the 
bladder  by  prostatic  carcinoma  is  the  rule. 

Symptoms. — In  an  early  stage  of  carcinoma  of  the  prostate  the  - 
symptoms  are  similar  to  those  of  chronic  enlargement,  viz.  difficulty 
and  frequency  of  micturition,  loss  of  projection  of  the  stream,  reten- 
tion of  urine,  and  finally  the  incontinence  of  overflow  ;  but  there  are 
1  See  also  Vol.  I.,  p.  556. 


<>20 


THE   PROSTATE 


important  differences,  and  afterwards  other  symptoms  are  added.  In 
the  first  place,  it  may  be  stated  briefly  that  the  symptoms  of  carcinoma 
are  much  more  rapidly  and  steadily  progressive  than  those  of  chronic 
enlargement,  and  that  the  interference  with  micturition  is  more  pro- 
nounced than  the  physical  signs  would  lead  one  to  expect. 

Pain  is  a  more  marked  and  earlier  feature  in  malignant  disease 
than  in  chronic  enlargement.     It  is  referred  to  the  end  of  the  penis, 

to  the  hypogas- 
trium  and  the 
perineum,  and, 
although  in- 
creased by  mic- 
turition, is  not 
relieved  by  it. 
It  is  also  very 
resistant  to 
treatment, being 
due  to  infiltra- 
tion of  the 
nerve  plexus  by 
the  carcinoma- 
tous growth. 
With  involve- 
ment of  the  sci- 
atic nerves,  pain 
extending  down 
the  leg  occurs. 
Tr  u  e  i  n- 
continence  of 
urine  may  be 
set  up  in  carci- 
noma, due  to  de- 
struction of  the 
bladder  sphincters,  but  only  towards  the  end  of  the  disease. 

Haematuria  is  rare  unless  there  is  ulceration  of  the  growth,  but 
it  has  nothing  to  distinguish  it  from  the  other  causes  of  bladder 
haemorrhage.  As  a  rule  it  is  slight.  Pieces  of  growth  may  be  passed 
per  urethram. 

Pyuria  is  always  present  when  the  growth  has  ulcerated  into 
the  bladder,  but  the  cystitis  rarely  reaches  a  severe  degree. 

Interference  with  defaecation  is  similar  to  that  occurring  in 
cases  of  simple  enlargement,  but  may  go  on  to  complete  obstruction. 
Ulceration  into  the  bowel  leads  to  haemorrhage  and  discharge  per 
rectum. 


Fig.  560. — Section  of  the  bladder,  prostate,  and 
rectum,  showing  carcinoma  of  the  prostate  ;  the 
bristle  is  in  the  common  ejaculatory  duct. 


CARCINOMA   OF  THE   PROSTATE  121 

Cachexia  is  marked  and  ocoura  early.  Jt  is  doI  relieved  by 
feeding  and  by  treatmenl  of  the  symptoms  of  urinary  infection,  as 
in  cases  of  simple  enlargement. 

Physical  signs. — The  prostate  should  be  examined  per  rectum 
after  taking  the  precaution  to  empty  the  bladder.  It  i.s  always  con- 
siderably enlarged,  and  the  surface  presents  marked  irregularities, 
which  are  usually  hard  and  nodular.  Hard,  conical  projections 
often  be  felt  extending  along  the  vesiculae  seminales  or  along  the  wall 
of  the  pelvis;  the  glands  in  the  pelvis  can  frequently  be  felt  to 
be  enlarged  and  hard.  The  rectal  mucous  membrane  is  not  freely 
movable  over  the  tumour. 

Examination  of  the  urethra  and  the  bladder  by  the  catheter,  sound, 
or  rystoscope  is  contra -indicated,  if  the  diagnosis  can  be  made  by 
rectal  examination,  as  likely  to  cause  severe  haemorrhage  and  cystitis. 
If  examination  of  the  urethra  is  carried  out,  only  soft  instruments 
should  be  used.  The  evstoscope  is  difficult  to  pass,  and  gives  little 
information,  especially  as  bleeding  rapidly  obscures  the  view.  In  a 
few  cases  the  growth  resembles  a  vesical  tumour,  but  a  differential 
diagnosis  is  at  once  made  on  rectal  examination.  Late  in  the  disease 
complete  retention  of  urine,  rectal  obstruction,  involvement  of  the 
ureters,  with  subsequent  hydronephrosis  and  pyonephrosis,  anaemia, 
and  secondary  deposits,  occur,  whilst  hypostatic  pneumonia  is  fre- 
quently the  direct  cause  of  death. 

Treatment. — In  the  great  majority  of  cases  palliation  of  the 
symptoms  is  the  only  treatment  possible.  The  pain  should  be  relieved 
by  morphia,  antipyrin,  hot  bottles  and  hot  applications.  For  the 
retention  of  urine,  catheterization  with  soft  catheters  is  permissible  if 
their  passage  does  not  cause  severe  pain  and  haematuria.  but  if  it 
does  so  a  permanent  suprapubic  opening  should  be  made.  All  local 
treatment  should  be  put  off  as  long  as  possible,  as  it  will  only  hasten 
retention  of  urine,  cystitis,  and  haematuria. 

The  radical  treatment  of  removal  is  sometimes  carried  out.  under 
a  mistaken  diagnosis  of  chronic  enlargement,  by  the  suprapubic  route, 
but  rapid  recurrence  is  inevitable,  and  the  danger  of  death  from 
haemorrhage  considerable. 

Lately,  attempts  at  radical  cure  have  been  made  by  removing  the 
entire  prostate,  the  seminal  vesicles,  the  vasa  deferentia,  and  the 
trigone  of  the  bladder  as  far  as  the  entrance  of  the  ureters,  but  it  is 
too  early  to  speak  of  the  results  of  this  treatment,  although  patients 
have  been  reported  as  being  alive  three  years  after  operation. 

NEUROSES 

Nervous  disturbances  of  the  prostate  are  of  three  kinds — hyper- 
aesthesia  of  the  gland,  hyperesthesia  of  the  mucous  membrane  of  the 


922  VESICULjE  seminales 

prostatic  urethra,  and  spasm  of  the  muscular  fibres  of  the  prostate 
causing  difficult}-  in  micturition.  All  three  are  usually  found  com- 
bined in  the  same  patient. 

Prostatic  neuroses  usually  occur  in  young  adults  who  have  either 
had  an  inflammatory  condition  of  the  urethra  and  prostate,  and  often 
much  treatment  for  it,  or  who  are  neurasthenic  and  have  indulged  in 
masturbation  or  sexual  excesses. 

In  the  first  variety  of  neurosis  the  patient  complains  of  a  feeling 
of  fullness  or  weight  in  the  perineum,  often  occurring  in  attacks.  On 
examination  of  the  urine  no  prostatic  threads  or  abnormal  contents 
are  found,  but  rectal  examination  shows  the  prostate  to  be  very  tender. 

If  the  neurosis  affects  the  prostatic  urethra,  similar  symptoms 
are  present,  and  the  passage  of  a  catheter  causes  severe  pain  as  the 
instrument  enters  the  bladder.  The  urethra,  however,  shows  no  sign 
of  inflammation,  and  there  is  no  discharge. 

The  spasmodic  variety  of  neurosis  of  the  prostate  is  the  most 
frequent  of  the  three,  and  is  characterized  by  difficulty  in  micturition, 
especially  in  the  initiation  of  the  act,  which  varies  from  time  to  time. 
As  a  rule,  this  difficulty  is  exaggerated  by  the  presence  of  others,  but 
it  may  be  present  and  necessitate  straining  even  when  the  patient  is 
alone.  The  passage  of  a  catheter  after  the  bladder  is  supposed  to  have 
been  emptied  will  often  demonstrate  residual  urine,  but  presents  no 
difficulties  except  a  slight  one  at  the  neck  of  the  bladder.  The  spas- 
modic obstruction  is  distinguished  from  those  due  to  organic  stricture 
of  the  urethra,  or  to  prostatic  enlargement,  by  the  facts  that  there 
is  no  lengthening  of  the  urethra,  that  the  difficulty  varies  from  time  to 
time,  and  that  a  large  catheter  passes  more  readily  than  a  small  one. 
The  condition  may  be  associated  with  attacks  of  spasm  of  the  detrusor 
muscle  of  the  bladder,  causing  urgent  micturition  without  pain  or 
difficulty. 

Treatment. — Any  inflammatory  condition  of  the  urethra  or 
prostate  should  be  attended  to,  and  the  patient  assured  of  the  absence 
of  serious  disease.  Too  much  local  treatment,  especially  if  it  be  painful, 
is  harmful  as  tending  to  increase  the  neurosis.  Passage  of  a  large 
sound  daily.,  with  the  general  treatment  of  neurasthenia,  will  often 
result  in  cure. 

THE    VESICUL^    SEMINALES 
ACUTE   VESICULITIS    (SPERMATO-CYSTITIS) 

Acute  vesiculitis  is  most  commonly  secondary  to  acute  urethritis, 
the  usual  cause  being  infection  by  the  gonococcus,  but  it  may  follow 
septic  urethritis  induced  by  instrumentation  of  the  urethra.  Other 
causes  are  prostatitis,  cystitis,  and  suppuration  after  removal  of  the 


VESICULITIS 


923 


prostate.      The    symptoms    and    treatmenl    are    deall    with    andei 
Gonorrhoea!  Spermato-Cystitis,  Vol.  I.,  p.  'vl;>- 


CHROXK     \  KSK.TLITIs    (Sl'KltM  \T<  >-(:YSTITIS) 

Chronic  vesiculitis  may  be  gonorrhoeal,  septic,  or  tubercular. 
first  two  may  be  considered  together. 


The 


Chronic  Septic  or  Goxorrhceal  Vesiculitis 
This   condition   usually   follows   a    urethritis   of  a  similar  nature, 
and  is  not  infrequently  preceded   by  an  acute  attack. 

Symptoms. — There  is  a  feel- 
ing of  weight  and  pain  in  the 
perineum,  and  frequently  also  a 
chronic  urethral  discharge  which 
on  endoscopic  examination  is 
found  to  come  from  the  ejacula- 
tory  ducts.  There  may  be  fre- 
quency and  pain  on  micturition, 
and  sexual  irritability,  leading  at 
first  to  increased  sexual  desire 
and  power,  and  later  to  diminu- 
tion of  the  sexual  appetite  and 
to  impotence.  On  rectal  exami- 
nation the  vesiculae  are  found  to 
be  enlarged  and  painful,  and  pus 
can  frequently  be  squeezed  from 
them  into  the  urethra.  Chronic 
urethritis  and  prostatitis  are 
often  concomitants. 

Treatment.— The  only  rational  treatment  for  this  condition, 
besides  the  administration  of  urinary  antiseptics,  is  the  emptying  of 
the  vesiculae  of  their  abnormal  contents  by  digital  manipulation.  The 
vesicular  are  stroked  from  above  downwards,  their  contents  being 
squeezed  into  the  urethra.  This  is  repeated  daily  until  relief  of  all 
symptoms  is  obtained  ;  but  the  condition  is  very  rebellious  to  treatment. 
In  old-standing  cases  it  may  be  justifiable  to  remove  the  vesiculae 
through  a  perineal  incision. 

Tuberculous  Vesiculitis  (Fig.  561) 
Tuberculous  vesiculitis  is  usually  associated  with  tuberculous 
disease  in  other  parts  of  the  genito-urinary  tract,  especially  in  the 
epididymis  and  the  prostate.  It  has.  however,  been  stated  that 
primary  disease  is  not  uncommon,  and  that  the  tuberculous  disease 
of  the  epididymis  is  secondary  to  vesiculitis. 


Fig.  561. — Section  of  a  vesicula 
seminalis,  showing  advanced 
tuberculosis. 


-f  THE   TESTIS 

Symptoms. — The  condition  La  usually  discovered  during  routine 
rectal  examination  in  cases  of  tuberculosis  of  the  testis,  prostate,  or 
bladder,  but  in  some  cases  the  first  symptom  may  be  the  appearance  of 
a  chronic  abscess  in  the  perineum.  There  are  frequency  of  micturition, 
a  feeling  of  weight  in  the  perineum,  and  occasionally  a  urethral  discharge. 

On  rectal  examination  the  vesicula  in  the  early  stages  feels  hard 
and  nodular,  but  later  the  nodules  soften,  and  in  advanced  cases  a 
soft  fluctuating  swelling  is  felt. 

Treatment — The  form  of  treatment  is  largely  determined  by 
ondition  of  the  other  parts  of  the  genito-urinary  tract.  In 
of  tuberculous  disease  of  the  testis  submitted  to  epididymectomy  or 
castration  the  corresponding  vesicula,  if  diseased,  should  be  removed 
at  the  same  operation  by  perineal  section,  and  this  plan  should  also 
be  followed  if  primary  disease  of  the  vesicula  is  diagnosed.  In  cases 
of  advanced  genito-urinary  tuberculosis,  general  treatment  is  all  that 
is  indicated.  Tuberculous  abscesses  should  be  opened  from  the 
perineum  and  the  contents  carefully  scraped  out. 

CYSTS,  CONCRETIONS,  AND  NEW  GROWTHS 
Cysts  of  these  organs  have  been  described,  and  are  usually  con- 
sidered  to  be  retention  cysts  due  to  stricture  of  the  duct.  Stricture 
of  the  common  ejaculatory  duct  is  very  rare,  and  it  is  probable  that 
most  cases  of  alleged  cysts  of  the  vesicula  have  little  to  do  with  these 
receptacles. 

(  oncretions  have  been  found  in  connexion  with  chronic  vesiculitis, 
but  they  are  very  rare. 

New  growths  are  usually  secondary  to  disease  of  the  prostate  ; 
primary  new  growths  are  so  rare  as  to  be  pathological  curiosities. 

THE    TESTIS 
CONGENITAL  ABNORMALITIES 

POLYORCHISM 

The  majority  of  reports  of  cases  of  polyorchism  are  untrustworthy, 
but  several  definite  cases  of  this  rare  condition  have  been  described. 
'July  cases  verified  by  dissection  and  microscopical  examination  should 
be  admitted,  for  encysted  hydroceles,  omental  hernia,  etc.,  have  all 
been  described  as  supernumerary  tesl 

ANORCHISM— MONORCHISM 

These  cases  are  more  frequently  met  with  than  cases  of  polyorchism, 
but  the  condition  still  remains  very  rare.  The  testis  alone  may  be 
absent,  or  any  or  all  parts  of  the  sexual  apparatus,  on  one  or  both 


CONGENITAL   ABNORMALITIES  925 

mditioD  Is  usually  associated  with  abnormalities  of  the 
external  sexual  apparatus. 

ANTERIOR    INVERSION 

Several  forms  of  inversion  of  the  testis  bave  been  described,  bu1 
anterior  inversion  is  the  only  one  of  interest.  It  is  said  to  occur  in 
one  in  every  twenty  males.  With  anterior  inversion  the  body  of  the 
testis  and  the  tunica  vaginalis  are  posterior,  whilst  the  epididymis 
is  anterior.  It  ao1  recognized,  the  condition  may  lead  to  errors  of 
diagnosis,  or,  more  important  still,  to  injury  of  the  testis  in  the 
tapping  of  ;i  hydrocele,  if  the  position  of  the  testis  has  not  been 
carefully  ascertained  beforehand. 

IMPERFECT   DESCENT 

In  the  early  stages  of  development  the  testis  is  situated  in  the 
abdomen,  below  the  kidney,  and  it  is  only  in  the  seventh  and  eighth 
months  of  foetal  life  that  it  descends  into  the  scrotum.  The  descent 
of  the  testis  is  governed  by  the  gubernaculum  testis,  a  fibro-muscular 
bundle  with  attachments  above  to  the  lower  pole  of  the  testis,  the 
globus  minor  of  the  ej^ididymis,  and  the  caecum,  and  below  to  the  skin 
at  the  bottom  of  the  scrotum  and  over  the  perineum,  the  symphysis 
I  hi  In-,  and  the  anterior  superior  spine  of  the  ilium.  In  the  course 
of  its  normal  descent  the  testis  passes  through  the  inguinal  canal  : 
its  arrest  at  any  point  constitutes  the  imperfectly  descended  testis  ;  its 
departure  from  the  normal  direction,  into  that  of  some  of  the  non- 
scrotal  fibres  of  the  gubernaculum,  the  ectopic  testis. 

The  testis  may  therefore  be  situated  in  the  abdomen,  in  the  inguinal 
canal,  just  outside  the  external  ring,  or  in  the  perineum,  over  the  sym- 
physis pubis  or  near  the  anterior  superior  spine.  The  testis  has  also 
been  found  in  Scarpa's  triangle,  having  passed  into  the  thigh  over 
Poupart's  ligament  after  it  had  issued  from  the  external  abdominal 
ring.  The  cause  of  imperfect  or  abnormal  descent  is  unknown,  but 
it  is  probably  intimately  connected  with  development  of  the  testis, 
as  the  incorrectly  placed  organ  is  nearly  always  undeveloped  and 
functionless  as  far  as  the  secretion  of  spermatozoa  is  concerned  ;  even 
if  spermatozoa  are  found  in  the  semen  of  a  cryptorchid  it  will  only 
be  at  puberty  or  soon  after,  the  imperfectly  descended  gland  under- 
going premature  atrophy. 

In  all  cases  of  imperfectly  descended  testis  the  processus  vaginalis 
is  to  be  found  in  the  scrotum,  but  the  upper  end  does  not  become 
shut  off  from  the  general  peritoneal  cavity,  and  the  patient  always  has 
a  potential  or  an  actual  inguinal  hernia.  Fluid  may  collect  in  the 
peritoneal  pouch  and  form  a  congenital  hydrocele. 

Diagnosis. — The   diagnosis   of  imperfectly   descended   testis   is 


926  THE   TESTIS 

made  by  finding  the  scrotum  empty,  and,  unless  the  gland  is  actually 
intra-abdominal,  by  feeling  the  organ  in  its  abnormal  position.  Obvious 
as  such  a  condition  would  appear  to  be,  mistakes  are  made  in  the 
case  of  young  children  with  very  mobile  testes.  In  these  children 
the  slightest  stimulus,  such  as  slight  coldness  due  to  removal  of  the 
clothing,  will  cause  the  testis  to  be  retracted  into  the  inguinal  canal, 
and  casual  examination  will  lead  to  error.  In  imperfect  descent  the 
organ  cannot  be  made  by  manipulation  to  reach  the  bottom  of  the 
scrotum,  but  the  merely  extremely  mobile  testis  can  readily  be  pressed 
down  into  its  proper  place. 

Treatment. — In  considering  treatment,  the  value  of  the  organ 
and  the  dangers  of  the  condition  must  be  taken  into  consideration.  It 
lias  already  been  pointed  out  that  the  imperfectly  descended  testis 
is  an  ill-developed  gland  usually  incapable  of  spermatogenesis,  but 
this  does  not  necessarily  mean  that  it  has  no  function.  As  is  well 
known,  removal  of  both  testes  in  a  young  subject  prevents  the  develop- 
ment of  the  secondary  male  characteristics,  probably  owing  to  lack  of 
the  internal  secretion  of  the  testes  ;  but  development  of  these  char- 
acteristics does  occur  in  cryptorchids,  showing  that  the  internal  secre- 
tion is  normal.  At  the  same  time,  it  is  also  well  known  that  one  testis 
is  sufficient  for  the  purposes  of  development,  and  therefore  the  loss 
of  the  internal  secretion  of  one  imperfectly  descended  testis  may  be 
ignored.  From  the  physiological  point  of  view,  consequently,  there  is 
no  benefit  to  be  gained  from  saving  one  imperfectly  descended  testis, 
nor  will  the  placing  of  such  a  testis  in  the  scrotum  lead  to  its  develop- 
ing active  spermatogenesis.  Further,  the  imperfectly  placed  organ  is 
specially  liable  to  certain  accidents  and  diseases.  In  the  perineum, 
in  the  inguinal  canal,  in  front  of  the  pubis,  or  in  Scarpa's  triangle, 
it  is  particularly  liable  to  injury  from  blows  and  subsequent  inflamma- 
tion and  atrophy.  The  abnormal  attachments  of  the  epididymis  and 
its  mesentery  may  lead  to  torsion,  whilst  malignant  disease  is  relatively 
more  common  in  the  imperfectly  descended  than  in  the  normally  placed 
testis. 

The  fact  that  imperfect  descent  is  complicated  by  a  patent  pro- 
cessus vaginalis,  and  that  radical  cure  of  hernia  is  easier  and  more 
certain  after  removal  of  the  testis,  must  also  be  taken  into  account. 
At  the  same  time  it  must  be  remembered  that  at  puberty  a  testis 
that  has  remained  in  the  inguinal  canal  will  sometimes  descend  into 
its  normal  situation  in  the  scrotum. 

In  all  cases  except  those  in  which  the  organ  is  in  the  abdomen, 
operation  is  indicated,  and  the  organ  can  either  be  (a)  fixed  into  the 
scrotum,  (6)  removed,  or  (c)  returned  to  the  abdomen. 

(a)  Orchidopexy  is  only  possible  in  the  exceptional  cases  in 
which  the  spermatic  vessels  are  long  enough  to  reach  the  bottom  of 


OPERATIONS   FOR   [MPERFEGT   DESCENT        >-i 

the  scrotum  without  tension,  whilst,  attempts  to  increase  the  > 
of  the  spermatic  cord  by  division  of  structures  and  inversion  of  the 
testis  usually  lead  to  atrophy  of  theorgan.  The  operation  of  orchido- 
pexy  Is  therefore  only  indicated  b  exceptional  cases.  Complete 
atrophy  and  re-asrenf  of  the  testis  are  common,  and  the  results  of  the 
operation  are  usually  disappointing.  The  steps  of  the  operation  are 
as  follows:  An  incision  is  made  over  the  external  abdominal  ring, 
as  in  Bassini's  operation  for  inguinal  hernia,  and  the  external  oblique, 
aponeurosis  divided  and  opened.  The  processus  vaginalis  testis  is  t  hen 
identified  and  opened,  and  the  testis  exposed.  The  peritoneal  process 
is  divided  above  the  testis,  and  the  upper  end  carefully  separated 
from  the  structures  of  the  spermatic  cord  and  ligatured  as  in  a  hernia 
operation.  The  testis  and  spermatic  cord  are  then  lifted  from  their 
bed,  pulled  downwards,  and  all  bands  of  fascia  carefully  divided  until 
the  cord  is  so  long  that  the  testis  will  lie  on  the  thigh,  three  or  four 
inches  below  Poupart's  ligament.  If  this  lengthening  cannot  be 
obtained  by  division  of  the  fascia  only,  the  spermatic  vessels  must  be 
divided,  and  the  testis  left  attached  merely  by  the  vas  and  artery  of 
the  vas.  The  forefinger  is  then  passed  into  the  scrotum,  and  a  pocket 
for  the  testis  made  there.  Into  this  pocket  the  testis  is  placed,  and 
held  in  position  by  a  purse-string  suture  passed  through  the  tissues 
above  it.  The  conjoined  tendon  of  the  internal  oblique  and  trans- 
versalis  is  then  sutured  to  Poupart's  ligament  above  the  vas,  and 
the  other  layers  of  the  abdominal  wall  closed  as  in  a  radical  cure  of 
hernia. 

(b)  Removal  of  the  testis. — This  is  the  operation  usually  per- 
formed for  imperfect  descent  on  one  side,  especially  if  the  case 
is  complicated  by  hernia  or  torsion ;  but  when  these  complica- 
tions do  not  exist,  little  harm  is  likely  to  result  from  waiting  for 
the  onset  of  puberty,  on  the  off-chance  of  descent  occurring  at 
that  time. 

(c)  Returning  the  testis  to  the  abdomen. — This  can  be  done 
when  both  testes  are  imperfectly  descended,  so  that  the  internal  secre- 
tion may  not  be  lost ;  but  it  must  be  remembered  that  torsion  and 
malignant  disease  are  more  apt  to  occur  in  these  organs,  and  that 
the  extension  of  any  inflammation  from  the  urethra  is  more  dangerous 
in  an  abdominal  than  in  a  scrotal  testis. 

The  hernia  which  so  frequently  complicates  imperfect  descent  of 
the  testis  should  always  be  treated  by  radical  cure  ;  trusses  designed 
to  allow  the  descent  of  the  testis  whilst  retaining  the  hernia  are  useless. 
When  the  radical  cure  is  performed  the  testis  should  be  removed,  to 
permit  more  complete  and  more  secure  closure  of  the  inguinal  canal. 
If  the  condition  is  bilateral,  one  or  both  testes  should  be  returned 
to  the  abdomen. 


928 


THE   TESTIS 


TORSION  OF  THE  SPERMATIC  CORD  (AXIAL  ROTATION 
OF  THE  TESTIS) 
Torsion  of  the  spermatic  cord  (Fig.  562)  is  associated  with  develop- 
mental errors  of  attachment  of  the  epididymis  and  the  common  mesen- 
tery to  the  testis,  and  these  errors  are  more  frequently  found  in  the 
imperfectly  descended  organ  than  in  one  normally  placed  in  the  scrotum. 
The  rotation  usually  takes  place  at  the  globus  minor,  and  is  of  such 

a  nature  that  the  testis  is  inverted  and 
the  globus  major  and  hydatid  are  found 
below.  The  twist  may  be  half  a  turn,  but 
as  many  as  four  turns  have  been  de- 
scribed. Although  this  condition  is 
always  associated  with  errors  of  develop- 
ment, the  exciting  cause  of  the  rotation 
is  unknown,  some  cases  occurring  during 
violent  exercise,  others  during  sleep. 
Clinically,  the  cases  may  be  divided  into 
acute  and  recurring. 


Fig.  562. — Torsion  of  the 
spermatic  cord. 


Acute  Torsion 
Symptoms. — The  patient,  usually 
the  subject  of  an  imperfectly  descended 
testis,  is  suddenly  seized  with  violent 
pain  in  the  groin,  vomits,  and  becomes 
collapsed,  the  symptoms  and  physical 
signs  closely  resembling  those  of  acute 
strangulated  hernia.  In  the  groin  a  firm, 
tender,  oval  lump  is  felt,  which  cannot  be 
separated  from  the  abdomen,  and  which 
has  no  impulse  on  coughing.  The  scrotum 
on  the  side  of  the  lump  is  empty,  and  the  skin  usually  red  and 
cedematous.  Fluid,  which  is  generally  blood-stained,  may  be  found 
in  the  vaginal  cavity. 

Results. — If  the  testis  be  removed  and  examined  it  will  show 
extreme  congestion,  extravasation  of  blood  into  every  part,  and  a 
purple  or  black  colour.  This  extravasation  of  blood  destroys  the 
testicular  substance,  so  that  atrophy,  winch  may  be  complete,  always 
follows.  In  a  few  cases  the  organ  becomes  infected  with  the  colon 
bacillus,  and  suppuration  with  sloughing  results. 

Treatment,  (a)  With  testis  in  the  scrotum. — If  the  case 
is  seen  soon  after  the  rotation  has  occurred,  an  attempt  should  be 
made  to  untwist  it.  This  has  been  successful  in  a  certain  number  of 
instances,  but  success  does  not  always  avert  subsequent  atrophy.  If 
the  attempt  to  untwist  is  not  successful,  the  testis  should  be  exposed 


TORSION   OF  THI-:   TKSTIS 


929 


and  removed,  although  if  the  twist  is  slight  and  the  extravasation  of 
blood  not  excessive  an  attempt  to  save  the  testis  may  be  made. 

(b)  Wiih  imperfectly  descended  testis  (Fig.  563). — In  these 
cases  the  testis  should  always  be  removed,  the  processus  vaginalis  se- 
parated and  liga- 
tured, and  the 
internal  abdomi- 
nal ring  closed. 

Recurring 
Torsion 

This  term  has 

been     given     to 

cases    in    which 

the  symptoms  of 

torsion  occur  at 

varying    periods 

over  a  course  of 

months  or  years.  The  symptoms 

.are  precisely  similar  to  those  of 

acute  torsion,  but  rarely  last 

longer  than  twenty-four  hours. 

Atrophy  does  not   necessarily 

occur,    but    frequent    attacks 

are,  of  course,  liable  to    lead 

to  destruction  of  the  organ. 

Treatment. — The  treat- 
ment in  an  early  case  consists 
of  undoing  the  rotation  by 
manipulation ;  sometimes  the 
patient  learns  to  do  this  him- 
self. If  the  condition  is  really 
recurring,  the  testis  should  be 
exposed  and  fixed  in  the  scro- 
tum by  suturing,  but  if  the 
testis  is.  imperfectly  descended 
it  should  be  removed. 


^ 


Fig.  563. — Dissection  of  an  imper- 
fectly descended  testis,  showing 
the  condition  which  is  liable  to 
result  in  torsion. 


INJURIES  OF  THE  TESTIS 

CONTUSED    WOUNDS 

These  wounds  are  due  to  blows  or  squeezes  of  the  testis,  and  result 
in   extravasation  of  blood.     The  extravasation  may  occur  into  the 
tunica  vaginalis  (traumatic  hsematocele),  into  the  testis  (haematocele 
34 


930  THE   TESTIS 

of  the  testis),  or,  very  rarely,  into  the  epididymis.  There  is  always 
accompanying  ecchymosis  of  the  scrotum.  Severe  contusions  of  the 
testis  are  rare,  owing  to  the  mobility  of  the  organ. 

Symptoms. — The  general  symptoms  are  often  severe,  and 
include  collapse  and  vomiting.  Locally  there  is  severe  pain,  especially 
if  haemorrhage  is  taking  place  inside  the  tunica  albuginea,  with  swelling 
and  ecchymosis  of  the  scrotum.  The  swelling  in  severe  cases  may 
extend  up  the  spermatic  cord  to  the  internal  abdominal  ring  (haemato- 
cele  of  the  spermatic  cord).  The  initial  symptoms  in  slight  cases  do 
not  last  long,  and  the  patient  may  resume  work,  but  in  a  few  hours 
orchitis  results,  and  the  pain  and  swelling  increase.  This  orchitis,  in 
which  the  epididymis  may  share,  lasts  for  some  days,  and  is  frequently 
followed  by  atrophy  of  the  testis. 

In  very  severe  contusions  the  tunica  albuginea  may  be  ruptured  ; 
marked  extravasation  of  blood  into  the  testis  without  rupture  of  the 
tunica  albuginea  is  very  rare. 

Results. — Mild  injuries  are  followed  by  complete  recovery,  but 
after  severe  injuries  some  amount  of  atrophy  is  the  rule  and  may  be 
complete.  Suppuration  rarely  follows.  In  a  large  number  of  cases  of 
malignant  disease  a  history  of,  injury  is  obtained,  but  it  is  doubtful 
whether  there  is  any  direct  connexion  between  the  two. 

Treatment. — After  slight  injuries,  rest  with  elevation  and  sup- 
port of  the  scrotum  is  all  that  is  necessary ;  but  ifj  the  pain  is  severe, 
an  incision  to  let  out  the  blood  is  advisable,  and  a  timely  incision 
may  possibly  in  some  cases  prevent  atrophy. 

Suppuration,  if  it  occur,  should  be  treated  by  incision  and  drainage. 

INCISED    WOUNDS 

Incised  wounds  require  the  same  treatment  as  similar  wounds  in 
other  parts  of  the  body,  and  have  like  complications  and  results. 

DISEASES  OF  THE  TESTIS 

INFLAMMATION 

Inflammation  of  the  testis  may  be  mainly  limited  to  the  body 
(orchitis)  or  to  the  epididymis  (epididymitis),  but  in  the  majority  of 
cases  both  parts  of  the  organ  are  affected,  and  the  condition  will  be 
described  under  the  term  epididymo-orchitis.  Those  cases  in  which 
the  body  of  the  testis  is  mainly  involved  will  be  indicated  after  epi- 
didymo-orchitis has  been  described. 

EPIDIDYMO-ORCHITIS 

Epididymo-orchitis  may  be  divided  into  acute,  subacute,  and 
chronic  forms,  but  a  classification  on  etiological  grounds  is  of  more 
importance.     The  condition  may  be  caused  by — 


SEPTIC    KPIDIDYMO-ORCUITIS  931 

(a)  Infection  of  the  testis  by  micro-organisms  which  have 
reached  the  organ  by  way  of  the  vas  deferens  from  the 
urethra,  prostate,  and  vesiculse  seminales.  By  far  the  most 
frequent  of  these  organisms  are  the  gonococcus,  staphylo- 
cocci, and  streptococci,  but  in  some  cases  the  tubercle 
bacillus  reaches  the  testis  by  this  route. 

(6)  Infective  micro-organisms  which  reach  the  testis  by  means 
of  the  blood-stream.  These  cases  are  secondary  to  the 
general  infective  diseases,  such  as  mumps,  typhoid  fever, 
scarlet  fever,  smallpox,  etc.,  or  are  due  to  invasion  by 
the  tubercle  bacillus  or  the  spirochsete  of  syphilis. 

(c)  Gout. 

(d)  Injury  and  strain. 

Gonorrheal  Epididymo-Orchitis 

This  important  variety  of  Epididymo-Orchitis  is  discussed  in 
Vol.  I.,  p.  839. 

Epididymo-Orchitis  of  Urethral  Origin  other  than  Gonor- 
rheal Urethritis — Septic  Epididymo-Orchitis 

The  most  frequent  causes  of  non-gonococcal  urethritis  are  septic 
organisms  which  invade  the  urethra  after  instrumentation,  operations 
on  the  urethra,  and  prostate,  the  passage  and  impaction  of  calculi  in 
the  urethra,  or  the  bursting  of  abscesses  from  the  vesiculse,  prostate, 
and  Cowper's  glands  into  the  urethra.  Urethritis  due  to  septic  organ- 
isms is  not  infrequently  followed  by  an  epididymo-orchitis  which  has 
the  same  symptomatology  and  physical  signs  as  that  due  to  the 
gonococcus,  and  at  first  demands  the  same  treatment. 

Prognosis. — Although  the  majority  of  cases  of  septic  epididymo- 
orchitis  end  either  in  resolution  or  in  fibrosis,  a  large  number  go  on  to 
suppuration.     This  pus  formation  may  occur  in  one  of  three  places  : 

(a)  In  the  tunica  vaginalis. — This  is  perhaps  the  most  common 
place,  the  fluid  present  in  the  tunica  in  all  cases  of  acute  epididymo- 
orchitis  becoming  more  or  less  purulent.  The  redness  and  oedema  of 
the  skin  are  most  marked  in  front  of  the  testis,  whei$  a  fluctuating 
swelling  forms,  from  which  pus  is  evacuated.  This  condition  does 
not  lead  to  fungous  testis  or  to  atrophy  unless  it  is  coexistent  with 
suppuration  in  the  testis. 

(b)  In  the  bodtj  of  the  testis. — Owing  to  the  dense  tunica  albuginea, 
suppuration  in  the  body  of  the  testis  is  frequently  associated  with 
gangrene  and  sloughing  of  the  organ.  The  body  is  much  enlarged,  and 
if  incisions  are  not  made  into  it  the  pus  bursts  externally,  frequently 
through  several  fistula?.  Complete  atrophy  of  the  testis  is  a  common 
sequel. 


932  THE   TESTIS 

(c)  In  the  epididymis. — If  suppuration  occur  in  the  epididymis  a 
fluctuating  swelling  forms  at  the  lower  and  posterior  part  of  the 
scrotum.  After  the  discharge  of  the  pus,  healing  occurs  by  fibrous 
tissue,  and  the  secretion  of  the  testis  is  usually  lost  to  the  semen. 

Treatment.  1.  The  urethritis. — The  patient  should  be  given 
urinary  antiseptics  and  sedatives  such  as  urotropine,  hetralin,  buchu, 
acid  sodium  phosphate,  etc.,  and  encouraged  to  drink  freely  of  bland 
fluids.  If  injections  of  astringents  and  antiseptics  into  the  urethra 
are  being  used,  it  is  probably  wise  to  discontinue  them. 

2.  General  treatment. — While  the  condition  is  acute  the  patient 
should  be  confined  to  bed  on  a  light  diet  and  the  bowels  freely  opened  ; 
the  more  complete  the  rest  in  bed  the  sooner  will  resolution  occur. 
Drugs  such  as  morphia,  antimony  tartrate,  anemone  pulsatilla,  sali- 
cylate of  soda,  etc.,  may  be  given  for  the  relief  of  pain.  Vaccine- 
therapy  has  also  been  employed  with  some  success. 

3.  Local  treatment. — The  testis  should  be  well  supported 
either  by  a  good  suspensory  bandage  or,  if  the  patient  is  in  bed,  on 
a  small  pillow.  For  the  first  forty-eight  hours  cold  may  be  applied 
either  by  means  of  an  ice-bag  or  by  evaporating  lead  lotion,  but 
warmth  in  the  shape  of  fomentations  equally  relieves  the  pain,  and 
probably  is  of  more  value  in  promoting  resolution. 

If  a  hydrocele  be  present  and  the  pain  intense,  relief  can  frequently 
be  obtained  by  puncturing  with  a  tenotomy  knife  and  allowing  the 
escape  of  fluid.  Counter-irritation  by  painting  the  scrotum  with 
silver  nitrate  (3i  ad  §i)  till  smarting  is  complained  of  will  often 
relieve  the  pain  and  allow  the  patient  to  get  about  if  this  is  necessary. 
Bier's  method  of  passive  congestion  can  also  be  tried.  As  soon  as 
the  acute  stage  is  over,  the  testis  should  be  carefully  strapped  to  pro- 
mote absorption  of  the  inflammatory  products,  and  the  strapping  with 
suspension  of  the  testis  should  be  continued  until  all  thickening  has 
disappeared.  This  treatment,  combined  with  the  giving  of  potassium 
iodide  and  injections  of  fibrolysin,  should  also  be  carried  out  for  simple 
chronic  epididymo-orchitis. 

If  suppuration  occur  the  abscess  should  be  carefully  opened  over 
the  most  prominent  part.  Great  care  should  be  taken  in  opening 
an  abscess  in  front  of  the  scrotum,  as  the  pus  is  frequently  confined 
to  the  cavity  of  the  tunica  vaginalis,  and  a  careless  incision  may  open 
the  tunica  albuginea  and  infect  the  testis. 

Incision  into  the  testis  with  a  tenotomy  knife  has  been  advised  in 
the  early  stages  of  epididymo-orchitis,  even  in  gonorrhoeal  cases.  The 
proceeding  is  not  without  danger,  and  is  probably  useless.  Excision 
of  the  fibrous  nodules  of  chronic  epididymo-orchitis  has  been  done,  but 
the  results  as  regards  sterility  are  doubtful.  In  cases  of  gangrene 
the  organ  should  be  excised  and  the  scrotum  drained. 


INFLAMMATORY   AFFECTIONS  933 

ORCHITIS 

Orchitis  may  occur  as  a  secondary  affection  to  epididymitis,  or 
the  inflammation  may  primarily  affect  the  body  of  the  testis,  the 
epididymis  being  only  slightly  involved.  Orchitis  is  much  rarer 
than  epididymo-orchitis,  and  is  due  to  injury,  gout,  or  infection  by 
one  of  the  organisms  of  the  specific  diseases,  particularly  epidemic 
parotitis  (mumps),  typhoid  fever,  smallpox,  scarlet  fever,  and  possibly 
rheumatism  and  influenza. 

Traumatic  orchitis  has  been  considered  under  Injuries  of  the 
Testis  (p.  932). 

Gouty  Orchitis 

Inflammation  of  the  body  of  the  testis  due  to  gout  is  very  rare, 
but  the  possibility  of  its  occurrence  may  be  considered  settled.  An 
acute  or  subacute  orchitis  develops  without  any  apparent  cause,  usually 
in  a  patient  who  is  middle-aged  and  gives  a  history  of  attacks  of 
articular  gout.  The  course  of  the  disease  is  tedious,  as  relapses  are 
apt  to  occur.  The  epididymis  is  only  slightly  affected  ;  but  a  condition 
of  epididymo-orchitis  secondary  to  gouty  urethritis  has  also  been 
described. 

Treatment. — The  treatment  consists  in  supporting  the  testes 
and  in  the  local  application  of  warmth,  combined  with  the  medicinal 
treatment  of  the  gouty  diathesis. 

Orchitis  of  Epidemic  Parotitis 

This  variety  of  orchitis  usually  develops  between  the  sixth  and 
the  eighth  day  of  the  parotitis,  and  is  much  more  common  in  some 
epidemics  than  in  others.  It  occurs  in  boys  and  young  adults,  being 
almost  unknown  in  childhood  or  old  age.  It  may  occur  in  an  epidemic 
without  the  development  of  parotitis,  or  it  may  precede  the  parotitis  ; 
in  some  cases  it  has  developed  after  inflammation  of  the  submaxillary 
gland,  without  any  involvement  of  the  parotid.  The  condition  is 
mainly  an  orchitis,  but  cases  of  epididymitis  have  been  described. 

Symptoms. — The  body  of  the  testis  becomes  tender,  hard,  and 
painful.  The  skin  of  the  scrotum  is  red,  and  there  may  be  a  secondary 
hydrocele.  The  condition,  though  usually  unilateral,  may  be  bilateral. 
The  orchitis  usually  rapidly  clears  up,  four  days  being  the  average 
duration  of  the  disease,  but  in  some  cases  atrophy  follows.  This  is 
particularly  apt  to  occur  in  older  patients,  and  is  more  common 
in  some  epidemics  than  in  others.  Should  it  occur  in  both  testes, 
impotence  or  even  infantilism  may  result. 

Treatment  consists  in  rest  in  bed,  warmth,  and  support  of  the 
testes.  The  patient  should  remain  in  bed  till  all  the  swelling  has 
disappeared. 


934  THE   TESTIS 

Orchitis  of  Typhoid  Fever 

Orchitis  occurring  in  typhoid  usually  appears  during  the  height  of  the 
disease,  but  it  has  been  known  as  early  as  the  seventh  day,  or  it  may  occur 
during  convalescence.  It  is  a  rare  complication.  The  inflammation  is  usually 
subacute,  and  may  not  be  noticed  owing  to  the  general  condition  of  the 
patient.  The  body  of  the  testis  becomes  hard,  tender,  and  swollen,  and  then 
gradual  resolution  takes  place ;  suppuration  and  atrophy,  although  not  un- 
known, are  rare.    One  testis  only  is  usually  attacked. 

Orchitis  of  Smallpox 

Orchitis  is  a  rare  complication  of  smallpox,  but  it  occasionally  terminates 
in  suppuration.    It  has  also  been  described  following  vaccination  for  smallpox. 

Orchitis  of  Scarlet  Fever,  Influenza,  and  Malaria 

Orchitis  is  an  extremely  rare  complication  of  these  diseases,  but  its  pos- 
sibility should  be  remembered  in  seeking  for  the  origin  of  an  otherwise 
unexplained  orchitis. 

Orchitis  and  Rheumatism 

The  cause  of  rheumatism  is  still  uncertain,  and  it  is  doubtful  if  rheumatic 
orchitis  really  exists.  Polyarthritis  is  very  frequently  of  gonorrhoeal  origin, 
and  it  is  possible  that  cases  described  as  rheumatic  are  really  cases  of  epi- 
didvmo-orchitis  secondary  to  gonorrhoeal  urethritis  which  is  complicated  by 
gonorrheal  arthritis. 

Orchitis  has  also  been  said  to  have  complicated  tonsillitis,  but  the  latter 
affection  may  be  due  to  such  different  causes  that  discussion  of  the  subject 
is  unnecessary. 

Epididymo-Orchitis  and  Strain 
The  connexion,  if  any,  between  epididymo-orchitis  and  strain  is  one 
of  great  importance,  as  it  is  not  infrequent  for  workmen  to  claim  com- 
pensation for  an  attack  of  epididymo-orchitis  which  is  alleged  to  have 
followed  the  lifting  of  a  heavy  weight.  Whether  epididymo-orchitis 
is  ever  due  to  strain  is  doubtful.  It  has  been  suggested  that  violent 
contraction  of  the  cremaster  muscle  due  to  great  muscular  effort  may 
cause  the  testis  to  strike  so  forcibly  against  the  pillars  of  the  external 
ring  as  to  produce  an  acute  epididymo-orchitis,  but  this  is  difficult  of 
proof.  Cases  of  epididymo-orchitis  of  obscure  origin  are  not  very 
uncommon,  and  it  is  easy  to  attribute  them,  in  the  absence  of  an  obvious 
cause,  to  an  alleged  strain,  but  great  care  should  be  taken  to  exclude  all 
other  possible  causes  before  this  is  suggested.  Many  cases  are  due  to 
gonorrhoeal  urethritis,  the  discharge  ceasing  for  a  time  when  the  testes 
are  attacked.  Others  are  cases  of  acute  tuberculosis,  or  are  due  to 
subacute  torsion  of  the  spermatic  cord.  This  last  condition  was  not 
recognized  by  the  older  writers  on  diseases  of  the  testis,  and  accounts 
for  many  cases  of  acute  epididymo-orchitis  of  apparently  unknown 
cause.  Acute  torsion  of  the  spermatic  cord  may  follow  a  muscular 
effort,  which  may  thus  be  the  exciting  cause  of  the  torsion,  the  pre- 


TUBERCULOUS    KPIDIDYMO-OKCI I1TIS 


935 


disposing  cause  being  a  congenita]  abnormality  <>f  the  attachments 
of  the  testis  [see  p.  930). 

Some  eases  of  cpididymo-orehit  is  may  be  due  to  thrombosis  of  the 
veins  of  the  pampiniform  plexus.  I  have  a  specimen  of  this  condition. 
The  onset  was  acute,  with  symptoms  of  acute  epididymo-orchitis,  and 
after  this  had  subsided  a  hard  lump  was  left  in  the  scrotum  just  above 
the  body  of  the  testis.  The  testis  was  excised  under  the  impression 
that  the  lump  was  a  malignant  tumour,  but  after  removal  the  con- 
dition of  thrombosed  veins  of  the 
pampiniform  plexus  was  obvious. 


fV 


>"•< 


I 


\vl 


Tuberculous  Epididymo-Orchitis 

Tuberculous  epididymo  -  orchitis 
is  usually  associated  with  tuber- 
culosis in  other  parts  of  the  genito- 
urinary tract,  especially  the  vesicular 
seminales  and  the  prostate.  The 
disease  may,  however,  be  most  ad- 
vanced in  the  testis,  and  it  is  prob- 
able that  in  some  cases  the  tuber- 
culosis is  localized  in  this  organ, 
the  organisms  reaching  the  affected 
part  by  the  blood-stream.  The  epi- 
didymis is  usually  attacked  before 
the  body  of  the  testis  (Fig.  564), 
perhaps  for  months  before  the  body 
is  affected.  Infection  of  the  epi- 
didymis can  occur  in  one  of  two 
ways — either  the  organism  has  in- 
fected the  vesiculse,  prostate,  or 
urethra,  and  reaches  the  testis  by 
spreading  along  the  lymphatics  of  the  vas  deferens  ;  or  it  reaches 
the  testis  by  the  blood-stream.  Both  these  methods  may  occur, 
but  probably  the  infection  is  most  commonly  conveyed  along  the 
vas  from  the  vesiculae,  winch  can  usually  be  shown  to  contain  tubercle 
bacilli  in  cases  of  tuberculous  epididymitis. 

The  disease  occurs  at  all  ages,  but  is  most  common  in  young  adults 
between  the  ages  of  20  and  30  years,  and  it  has  the  usual  etiology 
of  tuberculosis. 

Varieties.— Clinically  it  is  possible  to  distinguish  two  forms, 
an  acute  and  a  chronic.  The  acute  variety  has  a  sudden  onset, 
with  severe  pain  and  swelling  of  the  epididymis,  the  symptoms  and 
physical  signs  closely  resembling  those  of  acute  epididymo-orchitis 
of  gonorrhoea!  origin.     From  this  it  can  be  diagnosed  by  the  absence 


Fig.  564.- — Early  tuberculosis 
of  the  epididymis. 


93b 


THE   TESTIS 


of  urethral  discharge,  or,  in  the  rare  cases  in  which  this  is  present, 
by  isolating  the  tubercle  bacillus  from  the  exudate. 

The  chronic  variety  of  tuberculous  epididymo-orchitis  is  the  more 
common  (Fig.  565),  and  is  insidious  in  its  onset.  Usually  the  first 
thing  noticed  by  the  patient  is  a  small  painless  nodule  in  the  back 
part  of  the  testis,  associated  with  a  slight  aching  pain  in  the  part. 
On  examination  this  nodule  is  usually  found  to  be  in  the  globus 
minor  of  the  epididymis,  but  not  infrequently  it  is  situated   in  the 

globus  major.  This  difference 
of  situation  may  be  explained 
by  the  two  modes  of  infection. 
Thus,  if  the  infection  spreads 
along  the  vas,  the  globus  minor 
is  first  affected  ;  but  in  blood- 
borne  infection  the  globus  major 
suffers  first,  the  spermatic  ar- 
tery entering  the  epididymis 
near  the  upper  end. 

Signs. — When  the  disease 
is  moderately  advanced  it  pre- 
sents the  following  physical 
signs  :  The  skin  of  the  scrotum 
tends  to  be  adherent  to  the 
lower  and  posterior  aspect  of 
the  testis  ;  later  a  fluctuating 
swelling  will  form  at  this  point, 
burst,  and  discharge  pus.  The 
epididymis  is  enlarged  and 
nodular,  the  nodules  at  first 
being  firm,  but  later  becoming 
softened  in  the  centre.  The  vas 
is  often  normal,  but  sometimes  small  nodules  can  be  felt  in  it,  giving 
it  a  beaded  feel.  The  rest  of  the  cord  is  normal,  but  is  sometimes 
infiltrated  with  inflammatory  products,  especially  in  cases  of  mixed 
infection.  The  body  of  the  testis  appears  on  clinical  examination  to 
be  normal,  but  after  removal  small  tubercles  can  usually  be  seen  in 
it.  These  tubercles  are  most  numerous  near  the  mediastinum  testis. 
A  small  hydrocele  is  present  in  about  30  per  cent,  of  the  cases,  but 
is  not  a  prominent  feature  of  tuberculous  disease  of  the  testis.  On 
rectal  examination,  nodules  of  tubercular  deposit  can  frequently  be 
felt  in  the  vesiculse  and  prostate,  and  there  may  be  evidence  of  tuber- 
culous disease  of  other  parts  of  the  genito-urinary  tract,  especially  in 
the  other  testis.  The  disease,  if  not  treated,  usually  becomes  bilateral, 
although  it  is  generally  more  advanced  on  one  side. 


Fig.  565. — Advanced  tuberculosis  of 
the  epididymis  and  body  of  the 
testis. 


TUBERCULOUS   KPIDIDYMO-ORCHITIS  937 

Prognosis.  —  The    prognosis    of    acute   tuberculous    epididymo- 
orchitis  is  bad,  the  inflammation,  as  a  rule,  rapidly  terminating  in 

suppuration  and  sinus  formation.     In  the  acute  cases  also  the  body  of 
the  testis  is  affected  early  and  severely. 

The  prognosis  of  the  chronic  variety  is  better,  the  inflammation 
frequently  terminating  in  fibrosis  (Fig.  566),  but  in  the    majority  of 


Fig.   566. — Tuberculosis  of    the  testis  ending  in  fibrosis. 

It  is  difficult  to  distinguish  epididymis  from  body,  and  both  are  firmly  adherent  to  ihe  skin. 
The  condition  closely  simulates  malignant  disease. 

cases  suppuration  occurs  sooner  or  later.  The  prognosis  as  regards 
the  life  of  the  patient  depends  on  the  involvement  of  other  parts  of 
the  genito-urinary  tract. 

Treatment.  Acute  cases. — The  prognosis  in  the  really  acute 
case  is  so  bad  as  regards  saving  the  testis  that  castration  should  be 
advised  as  soon  as  the  diagnosis  is  made,  provided  the  disease  is  not 
advanced  in  other  parts  of  the  genito-urinary  tract. 

If  the  patient  will  not  agree  to  this  he  should  be  put  to  bed,  the 
testis  well  supported,  and  the  general  treatment  of  tuberculosis  carried 


938  THE   TESTIS 

out.  If  suppuration  occur,  consent  for  removal  of  the  testis  will 
often  be  given,  but  if  not  the  abscess  should  be  opened  and  the  disease 
eradicated  as  Ear  as  possible.  Epididymectomy  is  not  indicated  in 
acute  cases,  as  the  body  is  invariably  affected. 

Chronic  cases. — The  usual  constitutional  treatment  for  tuber- 
culosis should  be  carefully  carried  out,  and  beyond  supporting  the  testis 
in  a  suspensory  bandage  no  local  treatment  is  necessary.  Treatment 
by  injection  of  tuberculin  has  proved  of  value,  and  should  always 
be  tried  in  chronic  cases.  Bier's  method  of  passive  congestion  has  also 
been  used  with  success  in  cases  of  tuberculous  testis,  and  may  be  given 
a  trial  before  more  radical  methods  are  tried.  If  general  treatment 
fails,  and  the  condition  goes  on  to  suppuration,  one  of  the  three  follow- 
ing operations  may  be  advised  : — 

(a)  The  abscess  is  opened  and  the  diseased  parts  are  thoroughly 
scraped  with  a  sharp  spoon  so  as  to  remove,  as  far  as  possible,  all 
tuberculous  tissue.  This  may  be  followed  by  healing,  and  the  testis 
is  saved,  although  its  function  is  lost.  Frequently,  however,  a  sinus 
persists,  and  further  treatment  becomes  necessary. 

(b)  Epididymectomy. — In  this  operation  the  diseased  epididymis  is 
dissected  off  the  body  of  the  testis,  care  being  taken  to  save  the  vessels, 
and  an  attempt  made  to  obtain  healing  by  first  intention.  The  proce- 
dure has  the  advantage  of  leaving  the  patient  his  testis,  but  the  advan- 
tage is  a  sentimental  one,  as  the  organ  is  functionless.  Consent  for 
this  operation  can  often  be  obtained  when  castration  is  refused.  Its 
chief  value  is  in  those  cases  where  the  second  testis  has  already  been 
removed  or  is  the  seat  of  advanced  disease. 

(c)  Orchidectomy. — It  is  a  question  for  consideration,  in  all  cases 
of  tuberculous  epididymo-orchitis  in  which  the  disease  is  limited  to 
the  testis,  whether  early  castration  is  not  the  best  treatment.  The 
loss  of  one  testis  is  no  real  disadvantage  to  the  patient,  while  the  risk 
of  a  general  genito-urinary  tuberculosis  is  a  matter  of  supreme  import- 
ance. It  cannot  be  gainsaid  that  a  large  number  of  patients  with 
chronic  tuberculosis  of  the  epididymis  recover  and  remain  well  if 
general  constitutional  treatment  for  tuberculosis  is  efficiently  carried 
out ;  but  in  many  cases  the  disease  progresses  to  other  parts  of  the 
genito-urinary  tract,  leading  ultimately  to  the  death  of  the  patient. 
This  result  may  be  prevented  by  an  early  orchidectomy. 

When  castration  is  performed  for  tuberculous  disease  the  cord  and 
vas  should  be  removed  as  high  as  possible,  and  it  is  usually  advisable 
to  remove  the  vesicula  seminalis  at  the  same  operation. 

Tuberculous  Epididymo-Orchitis  in  Children 

Tuberculous  disease  of  the  testis  is  rare  in  children,  only  nine  cases 
being  diagnosed  in  the  London  Hospital  in   children  under  the  age 


SYPHILITIC   EPIDIDYMO-ORCHITIS  939 

of  12,  out  of  11,493  patients  under  thai   age.     The  disease  has  been 
Been  a  few  weeks  after  birth.     It   is  usually  insidious  in  onset,  and 

presents  the  same  physical  Bigns  as  in  the  adult.  bu1  associated  dia 
of  the  vesicular  and  prostate  is  uncommon.  The  disease  start-  in  the 
epididymis,  which  it  probably  reaches  through  the  blood-stream.  It 
is,  however,  frequently  associated  with  tuberculous  peritonitis,  and 
according  to  some  authors  with  tuberculosis  of  the  vertebrae  (Pott's 
diseaE 

Prognosis  is  bad,  the  inflammation  usually  ending  in  suppura- 
tion and  sinus  formation. 

Treatment. — This  does  not  differ  from  the  treatment  of  the 
disease  in  the  adult,  but  early  castration  is  to  be  advised,  to  prevent, 
if  possible,  infection  of  the  peritoneum.  Local  scraping  and  epididym- 
ectomy  are  unsatisfactory  in  these  small  testes. 

Syphilitic    Epididymo-Oechitis 

Syphilis  affects  the  testis  in  the  secondary,  intermediary,  tertiary, 
and  inherited  varieties  of  the  disease,  but  is  most  commonly  met 
with  in  the  intermediary  stage,  i.e.  two  to  four  years  after  infection. 

During  the  early  secondary  stage  the  epididymis  is  chiefly  affected, 
the  patient  suffering  from  a  symmetrical  subacute  epididymitis  which 
is  painless  and  mainly  localized  to  the  globus  major.  The  condition 
is  rare,  but  probably  frequently  passes  unnoticed  among  the  other 
manifestations  of  secondary  syphilis. 

In  the  intermediary  and  tertiary  stages  the  body  of  the  testis  is 
chiefly  affected,  the  lesion  being  a  chronic  orchitis  ending  either  in 
gumma  formation  or  in  diffuse  fibrosis  and  later  atrophy  of  the  testis. 
These  two  conditions  frequently  occur  together,  the  organ  on  section 
showing  a  general  fibrosis  with  small  gummata. 

Physical  signs. — In  a  well-marked  case  of  syphilitic  orchitis 
(see  Plate  79,  Vol.  I.,  facing  p.  746)  the  following  physical  signs  are 
present :  The  skin  of  the  scrotum,  at  first  normal,  becomes  adherent 
to  the  front  of  the  testis  ;  and  later,  if  the  disease  is  untreated,  a 
large  piece  of  the  skin  sloughs  away,  exposing  the  characteristic 
wash-leather  slough  of  a  gummatous  ulcer.  Through  the  hole  in 
the  skin  thus  made  the  testis  may  fungate.  The  body  of  the  testis 
is  at  first  uniformly  enlarged  and  painless,  but  later,  if  multiple 
gummata  form,  it  may  become  nodular.  The  organ  feels  light  if 
weighed  in  the  hand,  and  testicular  sensation  is  lost  early.  The 
epididymis,  vas  deferens,  and  spermatic  cord  are  usually  normal, 
but  thickening  of  the  vas  and  gummata  of  the  epididymis  have  been 
described.  If  the  epididymis  is  unaffected  it  is  frequently  difficult  to 
differentiate  it  from  the  enlarged  body.  Rectal  examination  reveals 
no  lesion  of  the  vesicuke  and  prostate,  and  there  is  no  enlargement  of 


940  THE   TESTIS 

the  abdominal  glands.  A  hydrocele  is  present  in  the  early  stages  in 
the  majority  of  cases  (Plate  105,  Fig.  1),  and  it  may  be  necessary 
to  draw  off  the  fluid  before  the  physical  signs  of  syphilitic  orchitis 
can  be  made  out.  Later  the  fluid  may  be  absorbed,  and  the  cavity 
of  the  tunica  vaginalis  completely  obliterated  by  adhesions.  If  a 
gumma  forms  and  softens,  fluctuation  may  be  obtained  in  the 
front  of  the  swelling.  When  fibrosis  follows,  the  body  of  the  testis 
becomes  hard  and  is  frequently  smaller  than  normal,  the  epididymis 
may  be  distorted,  and  a  large  hydrocele  is  frequently  present. 
With  atrophy  of  both  testes  sexual  desire  is  diminished  and,  later, 
impotence  may  follow. 

Diagnosis. — The  diagnosis  has  to  be  made  from  malignant  disease 
of  the  testis,  and  is  often  so  difficult  that  it  can  only  be  settled  either 
by  the  effects  of  treatment  or  by  an  exploratory  incision.  Wassermann's 
serum  diagnosis  (Vol.  I.,  p.  32)  is  valuable  in  these  cases. 

Treatment. — This  consists  in  giving  mercury  in  the  secondary 
stage  and  mercury  and  iodide  of  potassium  in  the  intermediary  and 
tertiary  stages.  Eesistant  cases  with  ulceration  and  fungous  testes 
may  be  treated  by  castration  combined  with  a  course  of  mercurial 
treatment. 

Inherited  Syphilis  of  the  Testis 

Inherited  syphilis  of  the  testis  is  rarer  than  tuberculous  disease  of 
that  organ  in  children,  but  is  met  with  in  children  a  few  months  old 
and  up  to  10  and  12  years.  After  that  time  it  is  extremely  rare,  but 
Fournier  has  described  a  case  in  a  young  man  of  24  years. 

The  body  of  the  testis  is  usually  affected,  although  cases  limited  to 
the  epididymis  have  been  described.  The  disease  usually  presents  itself 
as  a  diffuse,  painless  orchitis  ending  in  fibrosis  and  atrophy  of  the 
testis,  and,  if  bilateral,  as  it  generally  is,  may  result  in  infantilism. 
Gumma  formation,  leading  to  ulceration  and  fungous  testis,  may  occur, 
but  is  rare.  The  physical  signs  are  similar  to  those  of  the  acquired 
variety,  but  hydrocele  is  not  so  common. 

Treatment. — As  in  the  acquired  form,  this  consists  in  giving 
mercury  and  iodide  of  potassium. 

ATROPHY    OF    THE    TESTIS 

A  diminution  in  the  size  and  functional  power  of  the  testis  may 
be  either  the  result  of  inflammation  affecting  the  gland  (orchitis),  or 
a  degeneration  of  the  glandular  elements  without  supervening  fibrosis. 

Inflammatory  atrophy  may  follow  orchitis  from  any  cause,  such 
as  injury,  syphilis,  tuberculosis,  mumps,  etc.,  and  the  fibrosis  and 
atrophy  may  be  partial  or  complete  ;  usually  they  are  partial.  The 
testis  becomes  harder  and  smaller  than  usual,  and  is  frequently  nodular. 


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ATROPHY   OF  TIIK  TESTIS  941 

The  tunica  albuginea  is  thickened  and  wrinkled,  and  the  gland  on 
section  shows  bands  of  fibrous  tissue  running  in  all  directions,  tin- 
normal  testicular  substance  having  disappeared.  The  epididymis 
shaves  in  the  fibrosis  and  atrophy,  and  there  is  frequently  a  vaginal 
hydrocele.     The  condition  may  be  cither  unilateral  or  bilateral. 

Degeneration  atrophy  of  the  secretory  tubules  of  the  testis  may 
occur  from  various  causes.  It  may  be  due  to  interference  with  the 
blood  supply  by  injury  to  the  vessels  of  the  cord,  either  by  accident 
or  operation;  to  lesions  of  the  central  nervous  system,  either  cord  or 
brain  ;  to  pressure  from  an  old-standing  hydrocele  or  hernia  ;  or  it  may 
be  associated  with  some  grave  constitutional  disease,  such  as  diabetes 
or  leukaemia.  The  testis  in  this  form  of  atrophy  feels  soft  and  flabby, 
and  on  microscopical  examination  shows  fatty  degeneration  of  the 
essential  cells  without  increase  in  the  fibrous  connective  tissue.  The 
epididymis  shares  the  atrophy. 

Both  forms  of  atrophy  of  the  testis,  if  bilateral,  are  associated 
with  complete  or  relative  sterility.  In  advanced  cases,  spermatozoa 
are  completely  absent  from  the  semen  (azoospermia),  or  are  few  in 
number  (oligospermia) ;  and  if  the  atrophy  is  complete,  and  especially 
in  degeneration  atrophy,  the  patient  is  impotent. 

Atrophy  of  one  testis  has  no  effect  on  sexual  life,  provided  the 
other  testis  is  healthy. 

Treatment  must  be  directed  to  the  cause  ;  for  the  condition 
itself  nothing  can  be  done. 

ARREST    OF   DEVELOPMENT 

Arrest  of  development  of  the  testis  must  be  carefully  distinguished  from 
atrophy.  It  is  usually  found  associated  with  malposition  of  the  testis  ;  in 
fact,  all  misplaced  testes  are  maldeveloped  testes.  This  arrest  of  development 
of  the  testis  is  congenital,  and  may  affect  both  the  internal  and  external 
secretions.  Usually  it  interferes  with  the  external  secretion  only,  for  crypt- 
orchids  generally  develop  the  secondary  sexual  characters  of  the  male, 
although  as  a  rule  they  are  sterile.    There  is  no  treatment  for  this  condition. 

NEW  GROWTHS  OF  THE  TESTIS 

INNOCENT   NEW    GROWTHS 

Innocent  new  growths  of  the  testis  are  so  rare  as  to  be  patho- 
logical curiosities. 

The  following  varieties  have  been  described  : — 

(a)  Fibroma. — A  few  cases  have  been  reported,  but  the  descriptions 
of  nearly  all  of  them  suggest  that  the  disease  was  inflammatory  in 
origin. 

(0)  Osteoma. — It  is  doubtful  whether  true  bony  tumours  are  ever 
found  in  the  testis. 


942  THK    TESTIS 

(c)  Myoma. — This  tumour,  of  which  two  at  least  have  been  reported, 
is  believed  to  arise  in  the  remains  of  the  gubernaculum  testis. 

(d)  Adenoma. — Ticene  and  Chevason  have  described  small  nodules, 
never  larger  than  a  pea,  occurring  in  ectopic  testes,  which  they  think 
are  true  adenomas.  They  have  never  seen  them  in  the  normally 
placed  organ. 

MALIGNANT    NEW    GROWTHS 

Malignant  growth  of  the  testis,  whether  primary  or  secondary,  is 
rare,  only  about  '06  per  cent,  of  all  male  patients  admitted  to  the 
London  Hospital  suffering  from  this  disease.  These  growths  will  be 
considered  from  a  clinical  point  of  view. 

Malignant  disease  of  the  testis  may  occur  at  any  age,  and  may 
even  be  congenital.  It  usually  occurs  in  one  testis,  but  French  writers 
have  described  a  special  variety  which  has  a  tendency  to  attack  both 
testes  at  the  same  time.  It  appears  to  be  relatively  more  common  in 
the  imperfectly  descended  testis  than  in  the  normally  placed  organ, 
but  some  writers  have  denied  this  statement.  In  a  large  proportion  of 
cases  the  disease  appears  to  follow  injury  to  the  testis,  but  this  trauma 
may  only  be  the  means  of  calling  the  patient's  attention  to  what  is  a 
symptomless  disease. 

Clinical  symptoms. — These  at  first  are  absent,  but  later  there 
is  a  dragging  pain  in  the  groin  and  pain  across  the  loins.  Later  still, 
with  secondary  deposits  in  the  lumbar  glands,  there  may  be  sharp 
attacks  of  abdominal  pain,  and  the  usual  signs  and  symptoms  of 
malignant  cachexia. 

Physical  signs. — The  disease  nearly  always  affects  the  body 
of  the  testis,  primary  malignant  disease  of  the  epididymis  being  rare. 
The  body  becomes  uniformly  enlarged,  the  growth  for  a  long  period 
being  confined  by  the  tunica  albuginea.  Later  there  is  appearance 
of  localized  nodular  bulgings  of  the  tunica  albuginea,  of  a  softer  con- 
sistency than  the  rest  of  the  tumour.  If  the  tumour  contains  much 
cartilage  it  is  exceedingly  hard,  but  the  rapidly  growing  fleshy  growths 
with  a  large  amount  of  degeneration  of  the  tumour  tissue  feel  soft 
and  semi-fluctuant. 

Testicular  sensation  may  be  either  absent  or  present,  depending 
upon  the  stage  of  the  disease  and  the  amount  of  normal  testicular 
substance  remaining.  If  the  testicle  is  supported  in  the  hand  it  feels 
heavy.  The  epididymis  becomes  greatly  stretched  and  thinned  out 
over  the  enlarged  body  to  such  an  extent  that  in  the  majority  of  cases 
it  is  not  possible  to  differentiate  between  the  body  and  the  epididymis. 

A  general  or  localized  effusion  may  be  present  in  the  tunica  vaginalis, 
but  this  is  not  common.  In  a  few  cases  this  effusion  is  blood-stained. 
The  spermatic  cord  is  usually  unaffected,  except  that  it  is  a  little  thick- 


Rapidly  growing  malignant  tumour  of  the  testis,  with  secondary 
nodules  in  the  spermatic  cord. 

(Specimen  2039.  London  Hospital  Museum.) 

PLATE   106- 


MALIGNANT   DISEASE   OF   THE    IMS  IIS         943 

ened  by  the  increase  in  the  size  of  the  vessels  necessary  to  supply 
the  vascular  tumour  and  by  the  hypertrophy  <>f  the  cremaster  muscle 
thai  follows  the  increase  in  weight.  The  cord  may,  however,  be  infil- 
trated by  the  ue^  growth  and  become  nodular  (Plate  L06),  the 
nodules  varying  in  size  from  thai  <>i  a  pea  to  a  growth  as  Large 
normal  testis.    The  vas  deferens  remains  unaffected. 

The  skin  of  tlif  scrotum  is  al  firsl  normal,  bu1  later  large  dilated 
veins  can  be  seen  in  it.  With  advance  of  the  disease  the  skin  ceases 
to  move  freely  over  the  testis,  and  finally  becomes  firmly  adherent  al 
one  pari  :  through  this  the  tumour,  if  not  removed,  will  eventually 
fungate.  The  glands  affected  firsl  are  the  lumbar  glands,  situated  on 
the  front  of  the  lumbar  vertebraa  and  surrounding  the  aorta  and  the 
vena  cava  just  below  the  level  of  the  renal  arteries  and  veins.  A 
Large  deep-seated  mass  is  felt  on  one  side  of  the  spinal  column  near 
the  umbilicus.  This  mass  is  fixed  and  nodular,  and  does  not  move  on 
respiration.  Pressure  on  the  vena  cava  may  lead  to  dilatation  of  the 
superficial  veins  of  the  abdomen,  and  later  to  ascites  and  to  oedema 
of  the  lower  extremities.  Occasionally  the  inguinal  and  external  iliac 
glands  are  affected.  Metastasis  may  occur  to  any  part  of  the  body, 
but  is  most  common  in  the  lungs. 

Diagnosis  has  to  be  made  from  hsematocele,  hydrocele,  chronic 
orchitis,  and  tuberculous  disease.  From  hsematocele  the  diagnosis  is 
often  extremely  difficult,  especially  if  there  is  no  history  of  accident  ; 
in  such  cases  exploratory  incision  is  advisable  before  orchidectomy  is 
performed. 

Prognosis. — The  prognosis  is  extremely  grave,  largely  owing  to 
the  late  stage  of  the  disease  at  which  the  patient  usually  comes  under 
observation.  Early  removal  sometimes  results  in  complete  freedom 
from  recurrence. 

Treatment. — The  treatment  is  removal  of  the  organ  as  soon  as 
the  diagnosis  is  made.  This  should  be  done  even  if  there  is  evidence 
of  secondary  enlargement  of  the  lumbar  glands,  as  the  patient  will 
certainly  be  rid  of  a  source  of  inconvenience  and  the  danger  of  the 
growth  f ungating  will  be  avoided.     Local  recurrence  is  not  usual. 

Operation  is  contra-indicated  in  cases  of  advanced  disease  with  a 
large  lumbar  swelling  and  with  infiltration  of  the  cord,  as  the  growth 
will  fungate  through  the  wound  and  there  may  be  serious  difficulty  in 
stopping  haemorrhage  at  the  operation. 

The  question  of  the  removal  of  the  lumbar  glands  at  the  time  of 
removal  of  the  primary  growth  is  an  important  one,  as  the  modern 
operative  treatment  of  malignant  growth  demands  the  removal  ot 
the  nearest  set  of  lymphatic  glands  as  well  as  of  the  growth  itself. 
Attempts,  more  or  less  successful,  have  been  made  to  remove  the 
lumbar  glands,  and  there  can  be  no  doubt  that  this  is  the  correct  line 


944  THE   TESTIS 

of  treatment,  but  whether  it  can  usually  be  done  with  safety  to  the 
patient  has  yet  to  be  decided.1 

Pathology. — The  difficulty  of  classification  of  new  growths  is 
perhaps  more  marked  in  connexion  with  the  testis  than  with  any 
other  organ,  in  consequence  of  their  great  variety  and  complexity  of 
structure.  Recent  researches  and  observation  have,  however,  done 
much  to  simplify  the  confusion,  and  the  following  growths  can  now 
be  differentiated  by  the  microscope  : — 

1.  Sarcoma,  (o)  Round-celled. — These  tumours  show  in  every 
part  masses  of  small  round  cells  invading  the  normal  testicular  sub- 
stance.    They  are  the  most  common  form  of  sarcoma. 

(b)  Spindle-celled. — These  tumours  are  much  rarer  than  the  round- 
celled  growths,  but  show  the  same  structure  in  every  part  of  the 
growth. 

(c)  Lymphosarcoma. — These  tumours  show  the  reticular  structure 
of  lymph-glands,  but  are  hardly  to  be  differentiated  from  the  small 
round-celled  sarcomas. 

2.  Endothelioma — Endotheliomas  are  rare,  but  show  the  same 
histological  characteristics  in  the  testis  as  in  other  organs. 

3.  Carcinoma.— These  tumours  may  be  either  columnar-celled 
or  spheroidal-celled,  according  as  they  arise  in  the  ducts  or  in  the 
glandular  substance  of  the  testis,  or  frequently  the  cells  may  be  of 
comparatively  undifferentiated  type.  Like  the  sarcomas,  they  are 
uniform  in  structure,  and  are  exactly  comparable  with  carcinomas  in 
other  glandular  organs. 

4.  Teratoid  growths.     (See  Teratomas,  below.) 

TERATOMAS  2 

These  tumours  have  been  described  under  various  names ;  of 
these  the  most  common  are  fibro-cystic  disease  (Plate  105,  Fig.  2), 
adenoma,  chondroma,  chondroma  complex,  chondro-sarcoma,  chondro- 
carcinoma,  embryoma,  chorion-epithelioma.  These  names  indicate 
the  complex  nature  of  the  growths  and  the  extraordinary  diversity  of 
the  tissues  found  in  them  ;  examination  of  single  specimens  has  led 
to  great  difference  of  opinion  as  to  their  nature.  Clinically  they  may 
show  every  type,  from  a  slowly  growing  encapsuled  and  apparently 
innocent  tumour  to  a  highly  malignant  growth  destroying  life  by 
metastasis  in  a  few  weeks.  They  are  most  common  between  the  ages 
of  30  and  40. 

In  all  cases  examination  of  some  part  of  the  tumour  shows  a  simple 

1  Since  writing  the  above  I  have  removed  the  glands  lying  along  the 
aorta,  the  common  iliac,  and  the  external  iliac  artery,  in  a  boy  of  11,  with 
complete  success. 

2  See  also  Vol.  I.,  p.  586. 


DERMOIDS   OF   TIN-:  TESTIS  945 

fibrocystic  structure,  the  cysts  being  lined  with  a  columnar  or  flat- 
tened epithelium.  Bere  and  there  in  the  Btroma  m  I  true 
cartilage  arc  nearly  always  bund,  bu1  other  parts  of  the  tumour  may 
show  a  sarcomatous,  carcinomatous,  endotheliomatous,  or  chorion- 
epitheliomatous  structure.  The  metastasis  may  also  show  the  simple 
fibro-cysto-chondromatous  structure.  hut  in  other  cases  it  may  be 
sarcomatous,  carcinomatous,  or  choriou-cpitheliomatous. 

It  is  probable  that  these  growl  hs  arise  in  sex  cells  which  are  attempt- 
ing to  develop  under  some  unknown  stimulus. 

Clinically  the  only  diagnosis  possible  is  malignant  disease  of  the 
testis,  and  early  removal  of  the  testis  is  indicated  in  all  cases,  no 
matter  how  slowly  growing  the  tumour  may  be. 

DERMOID   TUMOURS 

Under  this  term  several  entirely  different  conditions  have  been 
described  : — 

(a)  Cases  of  malignant  teratoma  which  are  described  above. 

(6)  Pilo-sebaceous  dermoids  arising  in  the  skin  of  the  scrotum  and 
attached  to  the  testis,  but  not  in  or  of  it. 

(c)  Tumours  encapsuled  in  the  testis  and  containing  hair,  teeth, 
bone,  etc. 

If  the  term  dermoid  of  the  testis  is  to  be  retained,  it  should  indicate 
this  last  variety  only.  These  tumours  are  very  rare,  not  more  than  three 
or  four  having  been  described  in  England  in  the  last  five-and-twenty 
years.  They  are  congenital  in  origin,  but  may  not  be  recognized  until 
the  patient  has  reached  adult  life,  and  are  of  very  slow  growth.  At 
any  time  during  their  existence,  but  particularly  at  puberty,  they  may 
become  inflamed  and  suppurate,  discharging  hair,  teeth,  pieces  of 
bone,  etc.,  and  so  making  the  diagnosis  easy.  They  should  be  removed 
as  soon  as  diagnosed. 

MALIGNANT   DISEASE   OF   THE   EPIDIDYMIS 

Malignant  disease  of  the  epididymis  is  rare,  only  five  cases  being  found  in 
the  London  pathological  museums.  The  growth  is  usually  a  sarcoma,  either 
round-  or  spindle-eelled.  but  a  case  of  primary  squamous-celled  carcinoma 
has  been  described. 

The  treatment  is  removal  of  the  testis  as  soon  as  the  diagnosis  is  made. 

CYSTS  OF  THE  EPIDIDYMIS 
Cysts  of  the  epididymis  have  been  divided  into  two  classes  :  (a) 
small  superficial  cysts,  frequently  multiple  and  bilateral,  occurring  in 
men  over  40,  rarely  growing  larger  than  a  pea,  and  seldom  containing 
spermatozoa  ;  (b)  large  cysts  growing  in  the  substance  of  the  epididymis, 
usually  single,  occurring  in  men  under  40,  growing  slowly,  perhaps 
reaching  the  size  of  a  small  orange,  and  frequently  containing  sperrna- 
3:" 


940 


THE   TESTIS 


tozoa  (spermatoceles).  It  is  doubtful,  however,  if  these  two  classes 
are  distinct  from  one  another,  and,  as  the  exact  pathology  <>{  cysts  of 
the  epididymis  is  uncertain,  it  is  unnecessary  to  make  the  division. 

Pathology.— Probably  these 
cysts  do  not  all  arise  in  the  same 
way  ;  the  following  views  of  their 
origin  are  held  : — 

1.  They  are  retention  cysts  of 
the  tubules  of  the  epididymis  or 
vasa  efferentia.  2.  They  arise  in 
foetal  remnants  such  as  the  para- 
didymis (organ  of  Giraldes).  the 
vas  aberrans,  the  remains  of 
Midler's  duct,  or  the  pronephros 
(hydatid  of  Morgagni).  This  view 
would  make  them  analogous  to 
some  cysts  of  the  ovary  and 
embryonic  in  origin.  3.  They  are 
due  to  bursting  of  an  excretory 
tubule  into  the  connective  tissue 
round  the  epididymis.  4.  They 
form  in  the  connective  tissue  and 
have  a  secondary  connexion  with 
the  excretory  tubules. 

Pathological  anatomy. — 
Cysts  of  the  epididymis  most  com- 
monly occur  in  the  region  of  the 
globus  major  and  extend  upwards 
into  the  cord,  depressing  the  body 
of  the  testis  so  that  it  lies  more 
horizontally  than  usual.  (Fig. 
567.)  They  are  frequently  bila- 
teral, and  may  be  multiple  and 
loculated.  They  vary  in  size  from 
a  pin's  head  to  a  cyst  containing 
five  or  six  ounces  of  fluid,  and  are 
usually  of  very  slow  growth.  The 
fluid  contained  in  them  is  either 
Fig.  567. — Cyst  of  the  epididymis,     (a)   a  pale  limpid  fluid  with  only  a 

trace  of  albumin,  or  (b)  a  milky- 
white  opalescent  fluid  containing  some  albumin  and  many  sper- 
matozoa, either  living  and  active  or  dead  and  disintegrating  ;  it  is 
usually  the  large  cysts  that  contain  spermatozoa*.  The  cyst  may 
persist  in  spite  of  several  tappings,  or  may  disappear  after  tapping. 


CYSTS   OF   THE    EPIDIDYMIS 


'17 


There  is  usually  a  connexion  between  these  cysta  and  the  tubules 
oi  the  epididymis  or  vasa  efferentia,  bu1  in  man]  cases  qo  such  con- 
nexion can  be  demonstrated  by  injectioB  or  dissection. 

Symptoms.  Asa  rule  symptoms  axe  absent,  although  there  may 
be  some  pain.     Usually  attention  is  drawn  to  the  cyBts  by  chance,  <>r 

by  their  gradual  enlargement.     They  have  frequently  I n  mistaken 

for  extra  testes.  They  mostly  occur  in 
middle  life  <>r  old  age,  and  arc  of  no 
importance.  When  of  medium  size, 
such  a  cyBi  presents  <>n  examination  a 
rounded  or  lobulated,  translucent,  and 
painless  cystic  swelling  in  the  globus 
major;  it  is  attached  to  and  moves 
with  the  body  of  the  testis,  which  is 
more   horizontal   than   usual. 

In  small  cysts,  difficulty  in  the  re- 
cognition of  translucency  and  apparent 
solidity  owing  to  tenseness  may  confuse 
the  diagnosis;  large  cysts  may  envelop 
the  testis  and  simulate  hydroceles  of  the 
tunica  vaginalis,  but  may  be  distin- 
guished from  them  by  the  fact  that  on 
careful  examination  the  testis  can 
usually  be  found  below  and  free  from 
the  cystic  swelling.  The  cyst  may  sud- 
denly increase  in  size  and  become  pain- 
ful after  a  slight  blow;  tins  may  be 
the  first  intimation  to  the  patient  that 
he  has  a  pathological  condition  in  the 
scrotum. 

Treatment. — These  cysts  are  of 
slow  growth  and  painless,  and  therefore 
may  be  left  alone.  If,  however,  they 
increase  in  size  so  as  to  cause  incon- 
venience, they  may  be  tapped  from 
time  to  time,  or,  if  the  patient  should  desire  it,  they  may  be  removed 
by  dissection. 


Fig.  568. — Cyst  of  the 
tunica  albuginea. 


CYSTS    OF    THE    TUNICA  ALBUGINEA   (CYSTS    OF    THE 

TESTIS) 
These  cysts  are  exceedingly  rare,  only  one  or  two  specimens  having  been 
described.  They  arise  between  the  layers  of  the  tunica  albuginea,  and  are 
probably  due  to  injury  and  extravasation  of  blood.  So  rare  are  they  that 
the  diagnostic  points  are  unknown.  If  necessary,  the  treatment  is  removal. 
(Fig.  568.) 


THE   TESTIS 

OTHER  CONDITIONS  OF  THE   TESTIS 

NEURALGIA 

This  term  is  applied  to  a  painful  condition  of  the  testis  usually 
occurring  in  paroxysms. 

The  cases  have  been  classified  as  follows  : — 

(a)  Cas>  an  obvious  lesion. — These  cases,  though  rare, 
exist.  The  testis  is  the  seat  of  paroxysms  of  acute  pain,  although 
examination  in  situ  or  after  removal  fails  to  show  any  apparent  abnor- 
mality. The  pathology  is  quite  unknown,  but  there  may  be  a  history 
of  sexual  irregularities  or  ■      esses 

(b)  Cases  with  a  lesion  in  the  body  or  epididymis. — The  most  common 
of  these  lesions  are  small  nodules  of  fibrous  tissue  in  the  globus  minor 
of  the  epididymis,  the  result  of  a  gonorrhoeal  epididymo-orchitis.  The 
nodule  is  usually  acutely  tender,  and  the  pain  radiates  from  it.  Other 
lesions  are  small  cysts  of  the  epididymis,  fibrosis  of  the  body,  atrophy 
of  the  testis,  and  the  results  of  injury  to  the  testis.  In  the  case  of 
chronic  epididymo-orchitis  the  pain  is  perhaps  due  to  retention  of 
semen  behind  the  blocked  tubules  of  the  epididymis. 

(c)  Lesion  in  the  adnexa  of  the  testis  a?id  elsewhere. — The  two  most 
common  lesions  of  this  variety  are  varicocele  and  renal  or  urethral 
stone.  Pain  in  the  testis  in  varicocele  is  not  an  uncommon  symp- 
tom, although  it  may  be  entirely  absent  ;  whilst  pain  radiating  to 
the  testis  is  one  of  the  classical  symptoms  of  renal  colic.  Other 
conditions  with  which  intense  testicular  pain  is  sometimes  associated 
are  hydroceles,  small  fibrous  and  cartilaginous  tumours  in  the  tunica 
vaginalis,  and  pressure  on  the  nerves  by  a  new  growth  of  the  spine. 

Symptoms. — In  most  cases  there  is  constant  tenderness  of  the 
testis,  exaggerated  during  the  paroxysms  of  pain,  and  usually  extremely 
marked  in  any  nodule  that  may  be  present  either  in  the  testis  proper 
or  in  the  epididymis.  The  paroxysms  are  frequently  caused  by 
exercise,  slight  injury,  and  changes  of  temperature.  Coitus  in  some 
cases  relieves  the  pain,  but  in  others  it  appears  to  induce  the 
paroxysm-.  The  pain  starts  in  the  testis,  and  may  radiate  along  the 
spermatic  cord  to  the  lumbar  region.  It  is  usually  so  severe  that 
the  patient  is  incapacitated,  and  it  has  sometimes  induced  self- 
mutilation.  During  the  paroxysms,  which  may  last  from  a  few 
minutes  to  several  hours,  the  testis  is  frequently  retracted  owing 
to  spasm  of  the  cremaster  muscle. 

Treatment. — The  first  step  in  treatment  is  to  remedy  any  pre- 
existing disease  in  the  testis  and  its  adnexa.  A  varicocele  should  be 
ligatured,  cysts  of  the  epididymis  removed,  a  hydrocele  operated  upon, 
and  so  forth.  The  removal  of  the  pathological  condition  is  frequently 
followed  by  complete  relief  of  all  symptoms,  and  no  further  treatment 


\l  URALGIA   OF   THE   TESTIS 

nf  the  neuralgia  is  accessary.  In  other  cases  relief  of  the  pain  does  not 
follow  the  treatment  of  the  underlying  condition,  or  there  may  \»-  no 
apparent  organic  lesion  In  the  testis.  The  prognosis  in  these  cases  is 
not  good,  as  the  condition  is  very  rebellions  to  treatment,  which  is 
mainly  empirical.  Relapses  after  apparen.1  cure  are  common.  During 
the  attacks  of  pain  the  patienl  should  be  put  al  resi  in  the  horizontal 
position  and  the  testis  be  supported  by  a  Buspensory  bandage.  Local 
application  of  cold  or  heat  should  be  tried,  or  mild  counter-irritation 
of  the  scrotum  employed.  In  Bevere  attacks  it  is  necessary  to  L'ive 
morphia  to  relieve  the  pain  ;  quinine  and  aconite  have  been  employed 
for  the  same  purpose. 

Firm  pressure  of  the  spermatic  cord  against  the  symphysis  pubis 
for  fifteen  minute-  has  been  followed  by  relief  of  pain. 

The  general  health  should  be  considered,  and  especially  the  ques- 
tion of  sexual  hygiene,  as  some  cases  are  dependent  either  upon  sexual 
-es  and  irregularities  or  upon  sexual  continence. 

Operative  treatment. — The  operative  treatment,  other  than 
relieving  any  obvious  pathological  condition,  consists  in  removal  of 
the  testis.  Its  advisability  is  doubtful.  Cases  are  recorded  by  the 
older  writers,  such  as  Cooper,  Curling,  and  Blizard,  but  the  results 
were  not  all  satisfactory.  In  some  of  the  cases  in  which  relief  followed, 
the  testis  was  the  seat  of  obvious  disease  and  the  operation  was  justifi- 
able ;  but  when  no  lesion  exists,  removal  of  the  testis  has  been  followed 
by  recurrence  of  the  pain  in  the  spermatic  cord  or  even  in  the  other 
testis.  Castration  may  therefore  be  recommended  if  an  obvious  lesion 
of  the  testis  is  present,  which  cannot  be  remedied  in  any  other  way  ; 
but  if  no  lesion  exists  the  operation  is  unlikely  to  effect  a  cure.  In 
all  cases  the  patient  should  be  warned  of  the  uncertainty  of  relief 
following  castration. 

SPERMATORRHOEA 

This  term  implies  a  frequent  escape  of  seminal  fluid  at  other  times 
than  during  a  sexual  orgasm.  As  a  pathological  condition,  if  it 
exists,  it  is  exceedingly  rare.  Escape  of  seminal  fluid  not  infrequently 
occurs  during  defalcation,  especially  if  there  is  much  straining  at  stool 
with  the  passage  of  hard  faeces.  It  occurs  in  men  who  lead  a  conti- 
nent life,  and  is  a  purely  mechanical  effect,  the  faecal  mass  squeezing 
against  the  contents  of  the  seminal  vesicles,  which  are  between 
the  rectum  and  the  bladder.  It  is  a  perfectly  natural  and  harmless 
phenomenon.  Spermatozoa  may  also  be  found  in  the  urine  which  is 
first  passed  after  coitus  or  an  emission. 

Patients  who  have  for  a  long  time  indulged  in  sexual  excesses  or 
masturbation  not  infrequently  increase  the  irritability  of  the  sexual 
organs  to  such  an  extent  that  emission  takes  place  on  very  slight 


950  THE   TESTIS 

provocation,  and  often  with  incomplete  erection  of  the  penis  and  a 
minimum  of  pleasurable  feeling  ;  but  this  is  a  condition  of  irritability 
of  the  sexual  apparatus  with  frequent  emissions,  not  spermatorrhoea. 

Some  patients  also  suffer  from  frequent  nocturnal  emissions ;  but 
here  again  the  term  spermatorrhoea  is  not  applicable,  erection  and 
orgasm  being  present. 

The  alleged  disease  is  one  that  is  firmly  believed  in  by  the  laity, 
and  the  following  conditions  frequently  give  rise  to  the  fear  that  the 
patient  is  suffering  from  a  dreaded  disease  which  only  exists  in  his 
imagination  : — 

1.  Escape  of  a  little  prostatic  fluid  after  sexual  excitement  accom- 
panied by  complete  or  partial  erection  of  the  penis. 

2.  Frequent  nocturnal  emissions. 

3.  Escape  of  muco-pus  in  a  patient  who  has  a  general  or  localized 
urethritis,  prostatitis  or  vesiculitis,  or  Cowperitis. 

4.  Deposits  of  urates  or  phosphates  from  the  urine,  more  especially 
the  latter,  which  sometimes  appear  as  a  "  milky  "  deposit  at  the  end 
of  micturition. 

5.  The  normal  mucous  cloud  in  urine. 

Amongst  the  insane,  complaints  of  spermatorrhoea  are  frequently 
made,  and  they  may  be  attributed  by  the  patient  to  past  masturba- 
tion or  sexual  excesses  ;  but  the  condition  only  exists  in  the  diseased 
imagination. 

To  sum  up,  the  term  spermatorrhoea  is  a  misnomer,  and  should  be 
discarded  from  medical  literature. 

Nocturnal  Emissions 

The  occurrence  of  emission  of  semen  during  sleep  may  be  either 
physiological  or  pathological.  In  healthy  adult  men,  living  well  as 
regards  food  and  drink,  and  leading  a  continent  life,  nocturnal  emissions 
accompanied  by  voluptuous  dreams  and  erection  of  the  penis  are 
natural  if  they  do  not  occur  more  frequently  than  once  in  ten  days 
or  a  fortnight,  and  are  not  accompanied  by  any  bad  reaction  on  the 
general  health.  They  are  pathological  if  they  occur  more  frequently 
— for  example,  several  nights  in  succession  or  several  times  in  the 
same  night ;  if  they  are  not  accompanied  by  full  erection  of  the 
penis  ;  or  if  they  cause  the  patient  to  feel  weak,  irritable,  and  easily 
tired.  Pathological  nocturnal  emissions  usua  11  v  follow  sexual  excesses, 
habitual  masturbation,  irritation  from  a  tight  prepuce  or  inflamed 
prostate,  or  unhealthy  sexual  excitement  ;  or  they  may  be  the  result 
of  organic  disease  such  as  myelitis,  tabes  dorsalis,  or  general  paralysis 
of  the  insane. 

Treatment. — If,  on  careful  consideration  of  the  history  and  the 
effects  of  the  emissions,  the  condition  is  considered  physiological,  the 


HYDROCELE  <oT 

patient  should  be  frankly  assured  thai  the  condition  is  natural  and 
no  treatment  is  necessary.  For  frequent  emissions  with  bad  after- 
effi  reatment  consists  in  careful  sexual  hygiene  after  treatmenl 

of  any  local  condition  such  as  phimosis.    The  diet  should  be  sp 
and  unstimulating,  and  alcohol  is  to  be  avoided,  especially  in  the 
evening.     Mental  peculation,  with  a   sufficiency  of  healthy  outdoor 
rcises,  the  avoidance  of  prurient   thoughts  and  literature,  are  all- 
important.     Engorgement  of  the  prostate  in  the  early  morning,  du< 
the  full  bladder,  is  a  source  of  irritability,  and  can  be  readily  removed 
by  emptying  the  bladder  immediately  on  waking.    Cold  sponging 
the  genitals  or  cold  baths  are  also  useful.     Drugs  other  than  aperients 
are  of  little  use,  but   general  tonics  may  be  useful.     Sedatives  such  as 
bromide  of  potassium,  hyoscyamus,  cannabis  indica,  or  opium  may 
be  tried,  but  they  are  of  little  use  without  careful  regulation  of  the 
sexual  life. 

THE  SPERMATIC   CORD   AND  TUNICA  VAGINALIS 

HYDROCELE 

Hydroceles  may  be  either  primary  or  secondary,  and  it  is  advisable 
to  discuss  the  latter  first. 

Secondary  Hydrocele 

This  form  of  hydrocele  may  be  divided  into  acute  and  chronic. 

1.  Acute  secondary  hydroceles  are  generally  due  to  inflammations  or 
injuries  of  the  testis,  the  most  common  being  gonorrhceal  epididymo- 
orchitis,  but  they  also  occur  with  the  orchitis  of  the  specific  infective 
fevers.  These  hydroceles  are  cases  of  vaginalUis,  the  inflammation  of 
the  tunica  vaginalis  being  secondary  to  the  inflammation  of  the  testis, 
and  the  effusion  inflammatory  in  origin  and  nature.  The  condition 
is  frequently  unnoticed,  as  it  is  masked  by  the  symptoms  of  the 
acute  inflammation  of  the  testis,  and  the  treatment  is  identical  with 
the  treatment  of  the  primary  inflammation.  Resolution  is  by  far  the 
commonest  result,  but  suppuration  occurs  in  a  certain  number  of 
cases,  and  the  tunica  has  to  be  drained  (see  Acute  Epididymo-Orchitis, 
p.  933).  Acute  hydroceles  also  occur  with  acute  inflammation  of  the 
scrotum  or  spermatic  cord,  or  they  may  be  secondary  to  acute  torsion 
of  the  testis.     In  this  latter  condition  the  fluid  is  usually  blood-stained. 

2.  Chronic  secondary  hydrocele  is  also  generally  due  to  a  chronic 
vaginalitis  secondary  to  chronic  inflammation  of  the  testis,  as  in 
tubercular  epididymo-orchitis  and  syphilitic  orchitis. 

In  some  cases  chronic  hydroceles  are  passive  effusions  into  the 
cavity  of  the  tunica  vaginalis,  as  in  cases  secondary  to  neoplasm 
of  the  testis. 


952  SPERMATIC   CORD 

The  treatment  of  secondary  hydrocele  is  that  of  the  primary 
condition,  but  in  the  case  of  hydrocele  secondary  to  syphilitic  orchitis 
tapping  or  radical  cure  may  be  necessary. 

Primary  Hydrocele 

The  primary  form  of  hydrocele  may  be  acute  or  chronic.  Acute 
primary  hydrocele  due  to  an  acute  vaginalitis  is  rare,  but  cases  have 
been  described  of  acute  pneumococcic  and  acute  septic  infection  of 
the  tunica  vaginalis,  with  effusion  of  inflammatory  lymph  into  the 
tunical  cavity ;  and  it  is  possible  that  acute  rheumatic  vaginalitis 
occurs. 

Chronic  primary  hydrocele  may  also  be  due  to  a  chronic  vaginalitis 
such  as  tuberculous  infection  of  the  tunica,  which  is  most  common 
in  children,  and  is  frequently  associated  with  tuberculous  peritonitis  ; 
but  the  pathology  of  the  common  vaginal  hydrocele  is  unknown,  and 
it  will  be  described  under  the  title  of  primary  idiopathic  hydrocele. 

1.  Primary  Idiopatltic  Hydrocele  of  the  Tunica  Vaginalis 

Two  views  are  held  as  to  the  causation  of  this  disease  :  (1)  that 
■  condary  to  a  chronic  inflammation  of  the  testis  or  epididymis  ; 
(2)  that  it  is  a  passive  effusion  into  the  cavity  of  the  tunica  vaginalis 
from  unknown  causes. 

Of  these  two  views  the  latter  is  the  one  most  generally  held  by 
English  surgeons,  while  the  former  is  favoured  by  French  surgeons. 

The  condition  is  most  frequently  met  with  in  elderly  patients,  and 
especially  in  Europeans  resident  in  the  tropics,  but  it  may  occur  at 
any  age. 

A  preceding  or  accompanying  history  of  inflammation  of  the  testis 
or  epididymis  is  unusual,  the  patient  rarely  giving  any  cause  for  the 
disease. 

Pathological  anatomy.  Fluid. — The  usual  amount  of  fluid 
in  a  hydrocele  is  about  half  a  pint,  but  occasionally  hydroceles 
are  seen  containing  quarts  of  fluid.  The  fluid  closely  resembles  blood 
serum  ;  its  specific  gravity  is  about  1022,  and  it  contains  about  6  per 
cent,  of  albumin,  the  fluid  becoming  solid  on  boilmi:.  It  is  generally 
straw-coloured,  but  may  be  brownish  from  admixture  of  blood,  or 
mav  sparkle  from  the  amount  of  cholesterin  in  it .  It  contains  fibrinogen, 
and  therefore  coagulates  on  the  addition  of  blood  or  othersource  of 
fibrin  ferment. 

Tunica  vaginalis. — The  tunica  vaginalis  even  in  old-standing 
cases  may  be  simply  thinned  owing  to  the  pressure  of  the  fluid,  and 
show  no  other  feature.  On  injection  with  soft  paraffin,  long  finger- 
like  processes  may  sometimes  be  seen  projecting  into  the  connective 
tissue  of  the  scrotum.     In  other  cases  thickening  of  the  tunica  occurs, 


HYDROCELE   OF   THE  TUNICA    VAGINALIS     953 

causing  the  hydrocele  to  be  constricted  in  places,  ot  even  loculated. 
In  old  eases,  especially  those  that  have  been  tapped  many  times, 
fibrosis  of  the  tunica  may  be  present,  and  in  some  instances  the  walls 
of  the  sac  are  as  much  as  half  an  inch  in  thickness.  Calcification  of 
these  thickened  sacs,  which  arc  often  of  cartilaginous  hardness,  is  not 
infrequent.  In  rave  instances,  projecting  from  the  walls  of  the  sac 
or  lying  free  in  the  cavity  are  small  cartilaginous  or  fibrous  bodies. 
In  a  few  specimens,  inflammatory  adhesions  may  partially  obliterate 
the  cavity  of  the  tunica  and  localize  the  hydrocele  to  one  part. 

Testis. — In  long-standing  cases,  thickening  of  the  tunica  albuginea 
with  atrophy  of  the  testis  may  be  present,  due  to  the  pressure  of  the 
fluid,  but  this  is  rarely  important.  In  some  cases  the  distension  of 
the  digital  fossa  of  the  tunica  with  fluid  lifts  the  epididymis  away 
from  the  body  of  the  testis,  and  thus  thins  out  the  vasa  efferentia,  which 
may  be  so  pressed  upon  as  to  prevent  escape  of  spermatozoa  from 
the  gland,  and  in  this  way  double  hydrocele  in  a  young  subject  may 
lead  to  sterility.  In  some  long-standing  cases  the  testis  is  so  squeezed 
out  and  incorporated  with  the  wall  of  the  hydrocele  that  it  is  not 
immediately  discoverable  on  opening  the  hydrocele. 

Spermatic  cord. — This  is  sometimes  a  little  thickened  from 
hypertrophy  of  the  cremaster  fibres. 

Penis. — In  large  hydroceles  the  skin  of  the  penis  and  scrotum 
may  be  so  dragged  forward  that  the  penis  is  lost  in  it,  and  only 
represented  by  a  dimpled  fold  of  skin  resembling  the  umbilicus. 

Symptoms. — The  patient  rarely  complains  of  pain,  but  only  of 
the  discomfort  and  weight  of  the  distended  scrotum  or  the  difficulty 
of  micturition  and  inconvenience  if  the  penis  is  buried. 

On  examination,  a  pear-shaped  swelling  with  base  downwards  is 
found  distending  one-half  of  the  scrotum.  The  skin  of  the  scrotum  is 
unaffected,  and  the  fingers  can  get  above  the  swelling  and  grasp  the 
cord,  showing  that  there  is  no  communication  with  the  abdomen. 
Usually  the  scrotum  can  be  readily  folded  up  on  to  the  abdomen.  The 
swelling  is  found  to  be  translucent,  but  several  fallacies  in  connexion 
with  this  sign  may  occur.  In  the  first  place,  translucency  is  absent 
if  the  walls  are  very  thick  or  calcareous,  or  if  haemorrhage  has  occurred 
(hsematocele)  ;  in  the  second  place,  translucency  may  be  present  in 
a  hernia  of  a  child  if  it  contains  gut  distended  with  gas. 

The  testis,  when  distinguishable,  is  usually  found  below  and 
behind  the  fluid,  but  in  cases  of  inversion  of  the  testis  it  is  found  in 
front — a  point  of  great  importance  when  the  hydrocele  has  to  be  tapped. 
The  swelling  is  usually  plainly  cystic  to  the  touch,  and  has  no  expansile 
impulse  on  coughing.  The  affections  most  likely  to  cause  errors  in 
diagnosis  are  hsematocele,  cysts  of  the  epididymis  or  testis,  scrotal 
hernias,  and   neoplasms   of   the  testis ;    and   the   condition  may  be 


954  SPERMATIC   CORD 

complicated  by  the  presence  of  cysts  of  the  epididymis,  hydrocele  of 
the  cord,  or  hernia. 

Complications,  (a)  Rupture. — This  may  be  traumatic  or 
spontaneous  ;  in  the  latter  ease  it  may  occur  while  the  patient  is  quietly 
resting,  and  is  probably  due  to  the  giving  way  of  one  of  the  finger-like 
processes  described  above,  or  of  the  wall  at  the  site  of  a  previous 
tapping.  There  is  a  sharp  sudden  pain,  followed  by  alteration  in  the 
condition  of  the  scrotum,  the  definite  cystic  swelling  changing  to  a 
diffuse  cedematous  condition,  often  with  evidence  of  blood  extravasa- 
tion. The  penis,  prepuce,  and  the  other  half  of  the  scrotum  usually 
become  swollen.  The  pain,  as  a  rule,  steadily  increases,  and  causes 
the  patient  to  seek  relief.  Spontaneous  cure,  suppuration,  or  recur- 
rence of  the  hydrocele  may  follow. 

(b)  Inflammation  and  suppuration — These  terminations  are 
rare,  and  are  usually  due  to  definite  injury,  although  this  is  not 
absolutely  necessary. 

(c)  Transformation  into  haematocele  may  be  due  to  either 
tapping  or  injury,  or  may  occur  spontaneously  and  insidiously. 

Treatment. — Treatment  may  be  palliative  by  tapping,  or  cura- 
tive by  radical  operation.  Treatment  by  injection  of  various  irritants 
into  the  sac  is  obsolete. 

Tapping. — A  hydrocele  may  be  tapped  as  often  as  it  becomes 
inconvenient  on  account  of  its  size.  The  position  of  the  testis  should 
always  be  ascertained  before  tapping,  either  by  marking  its  position 
when  the  translucency  test  is  applied,  or  in  the  case  of  small  hydroceles 
by  feeling  it.  The  skin  of  the  scrotum  is  cleaned  in  the  manner  usual 
for  all  operations,  and  drawn  tensely  over  the  swelling  with  one  hand 
whilst  with  the  other  the  aseptic  trocar  and  cannula  is  plunged  through 
it  into  the  cyst,  the  puncture  being  usually  made  in  front,  but  always 
away  from  the  testis.  Care  should  be  taken  to  avoid  any  superficial 
scrotal  veins.  The  fluid  is  then  drawn  off,  the  cannula  removed,  and 
the  small  puncture  closed  with  a  little  collodion.  In  a  few  cases  no 
recurrence  follows  tapping,  but  as  a  rule  it  has  to  be  repeated  at 
intervals. 

Radical  cure. — This  can  be  advised  in  all  cases  except  when 
the  patient  is  elderly  or  debilitated  in  health,  and  it  is  usually  com- 
pletely successful,  though  recurrence  has  been  recorded.  Two  opera- 
tions are  advised,  and  it  is  immaterial  which  is  chosen — (a)  excision  of 
the  tunica  vaginalis  lining  the  scrotum,  or  (b)  inversion  of  the  sac. 

(a)  Excision  of  the  tunica  vaginalis  lining  the  scrotum. — It  is  doubtful 
if  the  old  division  into  a  parietal  and  a  visceral  layer  of  the  tunica 
vaginalis  can  be  maintained.  Some  authorities  consider  that  the  body 
of  the  testis  is  uncovered  by  a  serous  membrane,  but  that  the  organ 
projects  into  the  cavity  of  the  tunica  vaginalis  in  the  same  way  that 


HYDROCELE   OF   THE   TUNICA    VAGINALIS     955 

the  ovary  projects  into  the   peritoneum.     (Fi  ft  this  i 

excision  of  the  tunica  vaginalis  lining  the  scrotum  means  complete 
excision  of  the  tunica,  and  recurrence  is  most  unlikely. 

The  operation  is  a  simple  one,  and  is  easily  perron I  throug 

two-inch  incision  in  the  scrotum.  Care  should  be  taken  to  arresi 
all  haemorrhage,  even  from  the  smallest  bleeding-points,  otherwise  a 
troublesome  hasmatoma  may  result. 

(b)  Inversion  of  the  sac.    The  tunica  is  opened,  the  fluid  allowed 


Fig.  569. — Diagram  illustrating  the  two  theories  regarding  the 
relationship  of  the  tunica  vaginalis  to  the  testis. 

a.  Tunica  vaginalis  covering  the  testis  and  lining  the  scrotum  :  b,  tunica  vaginalis  lining  the 
scrotum,  but  not  covering  the  testis. 

ipe,  and  the  sac  simply  inverted,  with  or  without  suture.  Recur- 
rence is  rare. 

Treatment  of  rupture. — Rupture  may  either  be  treated  by 
rest  and  support  until  the  oedema  has  disappeared,  when  a  radical 
cure  may,  if  necessary,  be  performed,  or  the  operation  may  be 
done  as  soon  as  the  patient  comes  under  observation.  The  former, 
as  less  liable  to  be  followed  by  complications,  is  probably  the  better 
course  to  pursue. 

Treatment  of  suppuration. — As  in  cases  of  suppuration  else- 
where, the  abscess  cavity  should  be  opened  and  drained. 

2.  Infantile  Hydrocele  (Kg.  570,  i) 

In  this  variety  of  hydrocele  the  processus  vaginalis  is  closed 
above  at  the  internal  abdominal  ring,  but  the  part  lying  in  the  cord, 


956 


SPERMATIC   CORD 


that  normally  should  he  obliterated,  remains  patent  and  becomes 
filled  with  fluid.  The  condition  is  common,  and  appears  soon  after 
or  at  birth. 

Physical  signs. — A  fluid  swelling  extending  from  the  inguinal 
canal  to  the  bottom  of  the  scrotum,  translucent,  and  not  reducible. 

Treatment. — If  left  alone  the  hydrocele  frequently  disappears 
spontaneously,  or  it  may  not  return  after  tapping  several  times.  It 
is  very  seldom  necessary  to  perform  a  radical  cure  by  dissection. 


Fig.  570.— -Diagrams  of  varieties  of  hydrocele. 

1,  Infantile;  2,  bilocular  ;  :-!,  encysted  hydrocele  of  the  cord  ;  4,  congenital. 

3.  Bilocular  Hydrocele  (Fig.  570,  2) 
The  bilocular  hydrocele  shows  two  pouches — one  running  down 
into  the  scrotum  and  having  the  relationsliips  of  an  infantile  hernia, 
and  the  other  extending  up  into  the  abdomen  either  behind  or  in 
front  of  the  peritoneal  cavity.  The  abdominal  pouch  may  be  very 
large  and  extend  above  the  umbilicus  and  down  into  the  pelvis.  The 
condition  is  rare.  Haemorrhage  may  occur  into  the  sac  and  form  a 
bilocular  hsematocele. 

Symptoms. — The  diagnosis  will  be  made  by  finding  an  infantile 


HYDROCELE   OF  THI>:   CORD  957 

hydrocele  which  has  a  communication  wit  h  a  cysl  Lying  above  Poupart's 
ligament. 

Treatment. — The  hydrocele  may  be  tapped,  I >ui  it  b  better  to 
remove  it  by  dissection.     The  constriction  between  the  two  sacs  usually 

occurs  at  the  inguinaj  canal. 

4.  Diffuse  Hydrocele  of  the  Cord 

This  is  a  very  rare  condition,  the  cause  of  which  is  unknown.  It 
is  a  collection  of  fluid,  resembling  blood  serum  in  composition,  in  the 
meshes  of  the  connective  tissue  of  the  spermatic  cord. 

Symptoms. — The  patient  exhibits  a  pyriform  swelling,  the  base 
of  which  rests  on  the  top  of  the  testis,  whilst  the  apex  disappears 
into  the  external  abdominal  ring.  The  swelling  is  painless  and  dis- 
appears under  slight  continuous  pressure,  but  reappears  directly  the 
pressure  is  removed.  The  condition  is  somewhat  difficult  to  diagnose 
from  an  omental  hernia. 

Treatment. — The  hydrocele  may  be  tapped  and  the  fluid  with- 
drawn, but  it  soon  returns.  Radical  cure  consists  of  incision  and 
drainage. 

5.  Encysted  Hydrocele  of  the  Cord  (Fig.  570,  3) 
Although  cysts  may  arise  in  the  spermatic  cord  from  several  causes, 
the  above  term  is  given  to  a  cyst  formed  by  fluid  collecting  in  an 
unobliterated  portion  of  the  processus  vaginalis  which  is  closed  above 
and  below.  These  cysts  are  usually  found  in  children,  but  may  be 
discovered  at  any  age. 

Symptoms. — The  condition  presents  itself  as  a  small,  rounded, 
freely  movable,  translucent  cystic  swelling,  situated  in  the  cord  between 
the  testis  and  the  external  abdominal  ring.  The  cyst  moves  with  the 
testis  and  cannot  be  completely  reduced  into  the  abdomen.  In  some 
cases  the  cysts  are  multiple  and  may  communicate  with  the  peritoneal 
cavity.  Haemorrhage  may  occur  into  such  an  encysted  hydrocele, 
converting  it  into  an  encysted  hematocele  of  the  cord. 

Treatment. — In  young  children  the  cyst  may  disappear  spon- 
taneously or  after  tapping,  but  if  a  radical  cure  is  considered  advisable 
the  cyst  should  be  dissected  out. 

6.  Congenital  Hydrocele  (Fig.  570,  4) 
A  congenital  hvdrocele,  which  is  not  necessarily  manifest  at  birth, 
is  an  effusion  of  fluid  into  an  entirely  unobliterated  processus  vaginalis. 
It  may  be  present  on  one  or  both  sides  ;  if  bilateral,  causes  for  increase 
of  fluid  in  the  peritoneal  cavity,  such  as  tuberculous  peritonitis  and 
cirrhosis  of  the  liver,  should  be  sought,  the  hydrocele  merely  represent- 
ing an  overflow  from  this  cavity. 

Physical  signs. — There  is  a  translucent  pyriform  swelling  in  the 


958  SPERMATIC   CORD 

scrotum,  lying  in  front  of  the  testis  and  running  up  into  the  abdomen. 
There  is  frequently  an  impulse  when  the  patient  coughs  or  cries.  By 
steady  pressure  the  fluid  can  be  returned  into  the  abdomen,  Lmt  the 
sac  soon  refills  when  the  patient  stands  upright.  The  diagnosis  has 
to  be  made  from  congenital  hernia,  with  which,  however,  it  may  be 
complicated. 

Treatment. — As  the  condition  always  represents  a  potential 
hernia,  it  should  be  treated  as  a  hernia.  A  truss  must  be  worn  con- 
stantly for  two  years,  and  the  hydrocele  must  be  tapped  occasionally. 
As  this  treatment  is  irksome,  a  radical  cure  as  for  a  congenital,  hernia 
is  better  and  surer. 

HEMATOCELE    OF    THE    TUNICA   VAGINALIS 

By  this  term  is  meant  an  extravasation  of  blood  into  the  cavity 
of  the  tunica  vaginalis.     The  condition  is  not  common. 

Etiology. — In  the  majority  of  cases  a  hematocele  is  preceded 
by  a  hydrocele,  but  this  is  by  no  means  necessarily  so,  although  French 
writers  generally  believe  that  previous  inflammatory  conditions  of 
the  tunica  vaginalis  are  nearly  always  present  before  the  onset  of  the 
hsematocele. 

1.  Spontaneous  origin. — Li  some  cases  of  hematocele  the 
condition  appears  to  arise  without  any  cause.  The  most  careful 
questioning  both  before  and  after  the  diagnosis  is  established  fails  to 
elicit  any  history  of  injury,  strain,  or  previous  disease  of  the  testis  or 
its  covering,  and  examination  of  the  testis  after  removal  gives  no 
clue  to  the  origin  of  the  hsematocele.  It  is  possible  in  these  cases 
that  the  blood-vessels  are  primarily  at  fault,  but  this  has  still  to 
be  proved. 

2.  injury.— The  great  majority  of  cases  of  hematocele  are  due 
to  a  definite  injury,  perhaps  the  most  frequent  being  in  the  tapping 
of  a  hydrocele.  It  follows  in  one  of  two  ways  :  (a)  During  the  tap- 
ping a  vessel  is  injured  in  the  tunica  vaginalis,  which  rapidly  fills 
with  blood.  A  warning  of  this  may  be  given  at  the  time  of  tapping, 
by  the  escape  of  blood-stained  fluid  from  the  cannula,  (b)  A  vessel 
may  rupture  after  the  tapping,  owing  to  the  sudden  relief  of  pressure 
due  to  the  removal  of  the  hydrocele  fluid.  In  these  cases  the  swelling 
will  rapidly  return  after  tapping,  but  the  physical  signs  "will  alter 
from  those  of  hydrocele  to  those  of  hematocele.  Haemorrhage  into  a 
hydrocele  may  also  be  due  to  a  blow,  or  to  the  strain  of  muscular 
effort  or  even  coughing ;  and  for  the  same  reason  a  hsematocele  may 
occur  in  the  tunica  vaginalis  without  the  previous  formation  of  a 
hydrocele. 

3.  A  hematocele  may  in  rare  instances  be  secondary  to  a 
malignant  new  growth  either  of  the  testis  or  of  the  tunica  vaginalis. 


HEMATOCELE   OF   THE   TUNICA    VAGINALIS    959 

This  condition  is  rare,  although  small  localized  hydroceles  are  no1 
Uncommon  with  malignanl  tumours  of  the  testis. 

4.  With  acute  torsion  of  the  spermatic  cord  a  small  hematocele 
always  forms  in  the  oavity  of  the  tunica  vaginalis. 

Symptoms.  Clinically,  hematoceles  may  be  divided  into  two 
classes:  (1)  acute  cases,  which  usually  have  a  very  definite  history  of 
injury  and  in  which  diagnosis  is  generally  easy  ;  an.l  (2)  chronic  cases 
without  a  definite  history,  and  m  which  diagnosis  is  always  difficult 
and  often  impossible  without  exploratory  incision. 

Acute  hematocele.— The  onset  of  these  cases  is  sudden,  and 
follows  a  blow  on  the  scrotum  or  a  muscular  strain,  the  patienl 
usually  being  the  subject  of  a  hydrocele;  or  it  follows  the  tapping 
of  a  hydrocele. 

The  scrotum  rapidly  swells,  and  there  is  generally  marked  ecchy- 
mosis  of  the  scrotal  skin.  The  swelling  is  painful  and  tender,  semi- 
fluctuant  and  non-translucent.  As  a  rule  the  position  of  the  testis 
cannot  be  made  out,  but  it  is  usually  situated  below  and  behind  the 
swelling.  Tapping  causes  escape  of  blood  and  diminution,  but  not 
disappearance,  of  the  swelling.  If  left  the  eccliymosis  of  the  scrotum 
disappears,  the  pain  diminishes,  and  the  swelling  gets  smaller,  but  in  a 
few  cases  inflammation  terminating  in  suppuration  may  occur,  the 
physical  signs  changing  to  those  of  a  scrotal  abscess.  Complete 
resolution  of  a  haematocele  is  rare,  some  thickening  of  the  tunica 
vaginalis  and  blood-clot  remaining. 

Chronic  haematocele. — The  onset  in  these  cases  is  insidious, 
the  patient  giving  no  history  of  a  cause.  The  swelling  grows  slowly, 
but  usually  there  are  irregular  increases  in  size,  followed  by  retro- 
gression, suggesting  small  and  repeated  haemorrhages.  It  may  be 
months  before  the  hsematocele  grows  to  a  size  that  is  inconvenient  to 
the  patient. 

The  swelling  is  firm,  and  feels  solid,  and  is  not  tender  or  translucent. 
It  is  often  irregular  and  nodular,  and  testicular  sensation  cannot  be 
obtained.  It  is  frequently  impossible  to  ascertain  the  position  of  the 
testis  or  to  differentiate  between  body  and  epididymis.  The  cord  may 
be  thickened,  and  the  skin  of  the  scrotum  may  not  be  freely  movable 
over  the  swelling.  If  tapping  is  resorted  to,  no  fluid  may  escape  from 
the  cannula,  but  usually  there  issues  some  dark-brown  or  black  fluid 
containing  degenerated  blood-corpuscles  and  cholesterin.  In  these 
chronic  cases  as  in  the  acute,  inflammation  and  suppuration  may 
occur  and  cause  a  scrotal  abscess. 

Pathological  anatomy. — If  a  recent  case  be  examined  there 
may  be  no  definite  changes  in  the  tunica  vaginalis  or  in  the  testis,  the 
only  pathological  condition  found  being  blood,  partly  coagulated  and 
partly  fluid,  in  the  cavity  of  the  tunica  vaginalis  and  in  the  scrotal 


960 


SPERMATIC   CORD 


outside  the  tunica.  In  old-standing  cases  the  tunica  vaginalis 
is  thickened  sometimes  to  the  extent  of  three-quarters  of  an  inch,  and 
■red  internally  with  a  membrane  formed  by  organization  of  a  layer 
of  the  blood-clot.  (Fig.  571.)  The  cavity  is  filled  with  dark-brown]  or 
greyish  clot  and  a  dingy-brown  fluid  consisting  of  serum,  blood  pigment, 
degenerated  corpuscles,  and  cholesterin.     The  tunica  albuginea  testis  is 


Fig.  571. — A  large  hematocele. 

thickened,  and  there  may  be  marked  degeneration  and  fibrosis  of  the 
body  of  the  testis  and  the  epididymis,  although  a  haematocele  may 
exist  for  years  without  causing  any  considerable  damage  to  the 
gland.     The  spermatic  cord  may  be  much  thicker  than  normal. 

Diagnosis. — The  diagnosis  in  acute  cases  is  usually  very  easy, 
but  in  old-standing  cases,  especially  those  without  history,  the  diagnosis 
from  syphilitic  orchitis  and  new  growth,  and  especially  the  latter,  is 
very  difficult  or  impossible.  In  many  cases  castration  has  been  per- 
formed for  haematocele  under  a  mistaken  diagnosis  of  malignant  disease, 


ll  EMATOGELE  961 

or  luematocele  has  been  diagnosed  instead  oi  neoplasm  and  valuable 
lame  has  been  wasted. 

diagnosis  can  often  be  settled  by  watching  the  case  and  noting 
the  steady  increase   in    size   of   a   malignant   tumour ;    but   time   is 

t  in  this  way,  and  it  is  much  better  to  employ  an  expkn 
incision. 

Tht>  diagnosis  from  syphilitic  orchitis  is  made  by  tho  history  and 
by  noting  the  effect  of  the  administration  of  large  doses  of  iodide  of 
rium  and  mereurv,  or  by  the  employment  of  Wassermann's  serum 
test  (Vol.  I.,  p.  32). 

Treatment. — In  acute  cases  with  small  hsematoceles,  or  when 
the  condition  or  wishes  of  the  patient  do  not  permit  of  more  radical 
methods,  the  treatment  consists  of  rest  in  bed.  support  of  the  scrotum, 
and  tapping  with  a  large-sized  trocar.  If  the  case  is  seen  soon  after 
the  hematocele  forms,  an  ice-bag  or  evaporating  lead  lotion  may  be 
applied  to  the  scrotum. 

When  the  haematocele  is  very  large  or  old-standing,  or  has  been 
preceded  by  a  hydrocele,  an  operation  is  indicated,  and  this  results 
in  rapid  and  permanent  cure  of  the  condition.  Three  operations 
may  be  considered  : — 

1.  Incision  and  removal  of  the  blood-clot,  with  or  with- 
out drainage.  This  may  be  done  to  recent  large  hsematoceles  not 
preceded  by  hydrocele  or  associated  with  well-marked  changes  in  the 
testis. 

2.  Excision  of  the  tunica  vaginalis  lining  the  scrotum,  with 
removal  of  the  clot.  This  operation  is  similar  to  that  performed 
for  the  radical  cure  of  a  hvdrocele,  and  is  the  one  usually  to  be  advised 
in  hsematocele  ;  it  generally  results  in  permanent  cure.  In  cases  with 
a  greatly  thickened  or  calcareous  tunica  it  may  be  difficult  to  per- 
form, and  great  care  must  be  taken  to  arrest  all  haemorrhage. 

3.  Castration. — In  many  cases  the  subjects  of  hsematocele  are 
elderly  men,  and,  as  has  been  stated,  the  testis  may  be  very  atrophic. 
Before  operating  on  old-standing  hsematoceles  with  very  thick  walls 
it  is  well  to  obtain  permission  to  remove  the  testis,  and  to  do  this 
without  hesitation  if  the  operation  prove  long  and  tedious.  It  has 
the  advantages  of  speedv  recovery  after  the  operation,  and  a  certain 
freedom  from  recurrence. 

If  suppuration  occur  in  a  hsematocele,  the  swelling  should  be  freely 
opened  and  drained,  or  in  old-standing  cases  orchidectomy  should 
be  performed  and  the  scrotum  drained. 

HEMATOCELE    OF   THE   SPERMATIC   CORD 

Hematoceles  of  the  spermatic  cord  are  divided  into  encysted  and 
diffuse  varieties ;    both  are  rare. 
3/ 


962  SPERMATIC   CORD 

Encysted  Hematocele  of  the  Spermatic  Cord 

Is  produced  by  haemorrhage  occurring  into  an  encysted  hydrocele  of 
the  cord.  It  is  exceedingly  uncommon,  and  the  diagnosis  is  only 
made  on  exploring  a  swelling  of  the  spermatic  cord.  The  treatmenr 
is  removal. 

Diffuse  Hematocele  of  the  Spermatic  Cord 

Is  caused  by  rupture  of  one  of  the  veins  of  the  pampiniform  plexus, 
with  haemorrhage  into  the  cellular  tissue  of  the  cord.  The  cause  of 
the  rupture  may  be  a  blow  on  the  cord,  but  more  usually  it  is  a  result 
of  violent  muscular  exertion,  such  as  severe  straining  at  stool. 

Symptoms. — During  muscular  exertion  a  severe  cutting  pain  is 
felt  in  the  inguinal  region,  and  this  is  followed  by  the  appearance  of 
a  diffuse  semi-solid  swelling  in  the  cord,  extending  from  the  inguinal 
canal  to  the  top  of  the  testis,  which  can  usually  be  plainly  differentiated 
below.     Ecchymosis  of  the  scrotum  often  follows. 

Treatment. — A  small  hsematocele  may  be  left  to  be  absorbed, 
but  if  it  is  large  the  swelling  should  be  incised,  the  clot  removed,  and 
the  bleeding-point  secured. 

VARICOCELE 

A  varicocele  consists  of  a  varicose  enlargement  of  the  veins  of  the 
pampiniform  plexus  and  the  spermatic  cord.  The  disease  rarely,  if 
ever,  affects  the  spermatic  vein  in  the  abdomen,  nor  are  the  veins 
accompanying  the  artery  to  the  vas  affected.  The  superficial  veins  of 
the  penis  and  scrotum  are  frequently  enlarged  and  tortuous.  The 
condition  is  much  more  frequently  seen  on  the  left  side  than  on  the 
right,  but  both  sides  may  be  affected. 

Varicocele  is  most  frequently  met  with  in  adolescents,  and  is  rarely 
seen  in  middle-aged  or  old  men,  although  a  varicocele  present  in  youth 
may  persist  throughout  life. 

Etiology. — The  cause  is  unknown,  but  the  condition  is  probably 
a  congenital  abnormality  of  the  spermatic  veins  exaggerated  by  the 
feeble  flow  of  the  blood  through  them  on  account  of  the  long,  narrow, 
tortuous  course  of  the  spermatic  artery  and  the  assumption  by  man 
of  the  upright  posture.  Dilatation  of  the  veins  of  the  pampiniform 
plexus  may,  however,  be  entirely  due  to  back-pressure.  This  is  seen 
in  the  varicocele  that  sometimes  accompanies  neoplasms  of  the  left 
kidney,  as  the  result  of  invasion  of  the  renal  vein  and  blocking  of 
the  left  spermatic  vein.  A  varicocele  arising  in  an  elderly  subject 
should  always  lead  to  examination  of  the  kidney. 

The  reason  of  the  greater  frequency  of  varicocele  on  the  left  side 
is  unknown,  in  spite  of  many  ingenious  theories,  the  chief  of  which  are 
— the  entrance  of  the  left  spermatic  vein  into  the  left  renal  vein  at  a 


VARICOCELE 


963 


right  angle  ;  the  presence  of  the  iliac  colon  on  the  left  side  pressing  on 
the  vein;  the  greater  contraction  of  the  muscles  on  the  left  side  of 
the  abdomen  owing  to  the  more  extensive  use  <>f  the  right  arm. 

Pathological  anatomy.  —The  veins  of  the  pampiniform 
plexus  are  lengthened,  dilated,  tortuous,  and  increased  in  number 
(Fig.  572).  Their  muscular  coats  become  atrophied,  and  there  is 
fibrosis  of  the  adventitia,  bo  thai 
the  walls  are  thickened  and  the 
veins  stand  open  like  arteries  when 
cut  across.  Phleboliths  may  be 
present  in  them.  The.  skin  of  the 
scrotum  is  lax,  thin,  and  moist,  and 
is  deficient  in  the  power  of  healthy 
contraction.  The  testes  are  very 
pendulous,  and  the  patient  may 
complain  that  the  left  testis  is 
atrophic.  It  is  extremely  doubtful 
if  varicocele  ever  leads  to  serious 
atrophy  of  the  testis,  and  certainly 
in  the  great  majority  of  cases  there 
is  no  loss  of  sexual  power  even 
with  a  very  large  varicocele. 

Symptoms.  —  The  disease  is 
most  frequently  discovered  on 
medical  examination  prior  to  enter- 
ing one  of  the  public  services,  the 
patient  being  unaware  that  he  has 
any  pathological  condition.  In  some 
cases  there  is  a  feeling  of  weight 
and  discomfort,  increased  by  stand- 
ing, exercise,  or  hot  weather,  and 
in  others  there  are  attacks  of  pain 
which  may  be  severe  (neuralgia  of 
the  testis).  The  condition  is  readily 
recognized  from  the  long,  lax  con- 
dition of  the  scrotum,  the  charac- 
teristic feel  of  the  distended  veins. 
*:  like  a  bag  of  worms,"  and  the  dilated  and  tortuous  veins  of  the 
scrotum.  On  recumbence  it  is  less  marked,  but  it  is  aggravated  by 
standing,  warmth,  and  exercise.  To  the  patient  the  testis  may  feel 
more  flabby  than  on  the  normal  side,  but,  as  stated  above,  atrophy 
is  rare. 

Treatment. — This  may  be  either  palliative  or  operative.     The 
former  consists  in  wearing  a  suspensory  bandage,  the  best  variety  being 


.372. — Dilated  veins  from 
a  varicocele. 


964  SPERMATIC   CORD 

Keetlev's.  The  patient  should  be  assured  that  atrophy  of  the  testes 
and  loss  of  virility  "will  not  occur,  and  should  be  treated  on  general 
lines  for  neurasthenia,  if  present.  Operation  should  be  reserved 
for  very  large  varicoceles  which  cause  severe  discomfort  and  pain  or 
interfere  with  the  patient's  work  or  exercise,  and  is  contra-indicated 
when  neurasthenic  symptoms  are  well  marked.  By  far  the  most  usual 
object  of  operating  is  to  enable  the  patient  to  enter  one  of  the  public 
services.  The  wisdom  of  rejecting  candidates  because  they  have  a 
varicocele  is  doubtful,  as  the  condition  is  in  itself  seldom  a  source  of 
trouble. 

The  operation  consists  in  removing  an  inch  or  so  of  the  anterior 
group  of  veins  of  the  spermatic  cord,  the  small  posterior  group  running 
with  the  artery  to  the  vas  being  carefully  preserved.  The  veins  should 
be  exposed  just  where  they  are  entering  the  external  abdominal  ring, 
and  it  is  useless  to  attempt  to  separate  the  spermatic  artery  from 
the  veins.  This  artery  is  nearly  always  included  in  the  ligature,  but 
if  the  artery  to  the  vas  and  its  veins  are  preserved,  as  well  as  the  sym- 
pathetic plexus  of  nerves  running  with  it,  atrophy  of  the  testis  does  not 
ensue.  The  operation  is  frequently  followed  by  an  epididymo-orchitis, 
but  if  suppuration  does  not  occur  the  condition  soon  disappears.  Pain 
from  the  inclusion  of  the  ilio-inguinal  nerve  in  a  ligature  may  follow 
the  operation,  and  neurasthenics  may  complain  of  pain,  atrophy  of 
the  testis,  and  loss  of  virility; 

ENDEMIC   FUNICULITIS 

Endemic  funiculitis  is  an  acute  inflammation  of  the  spermatic  cord 
which  occurs  in  certain  tropical  and  subtropical  countries. 

The  cause  is  unknown,  but  it  is  undoubtedly  due  to  bacterial 
infection,  and  a  diplococcus  has  been  isolated  from  the  affected 
tissue. 

The  pathological  anatomy  is  that  of  an  acute  inflammation 
of  the  cellular  tissue  of  the  cord  with  a  thrombosis  of  the  veins  of  the 
pampiniform  plexus.     Suppuration  is  the  common  termination. 

Symptoms — The  onset  of  the  disease  is  sudden,  with  constipa- 
tion, vomiting,  and  a  raised  temperature.  These  symptoms,  with  the 
physical  sign  of  a  painful  swelling  in  the  scrotum  extending  up  to 
the  abdominal  rings,  suggest  strangulated  hernia,  but  the  signs  of 
inflammation  are  more  marked,  while  the  general  symptoms  are  not  so 
severe.  The  skin  over  the  swelling  is  red  and  oedematous,  and 
there  is  no  impulse  on  coughing.  With  suppuration,  the  swelling 
becomes  soft  and  fluctuating,  and  there  is  sloughing  of  the  testis. 

Treatment. — The  whole  of  the  cord  and  the  testis  should  be 
excised  and  the  scrotum  drained  in  severe  cases,  but  in  the  milder 
forms  free  incision,  drainage,  and  fomentation  will  suffice. 


ABSENT    PENIS     WKBBK1)    PENIS 


965 


THE  PENIS 
CONGENITAL  ABNORMALITIES 

A  lis EXCE    OF   THE   PENIS 

Absence  o\  the  penis  is  very  rare,  and  in  reported  cases  the  urethra  has 

opened  into  the  rectum.  Apparent  absence  is  more  common,  a  small  penis 
being  hidden  in  the  pad  of  fat  over  the  symphysis  pubis.  In  a  case  under  my 
care4the  penis  in  a  healthy  child  was  represented  by  a  small  depression  above 


the  scrotum,  through 
which  the  urine  was 
voided.  A  small 
penis  was  dissected 
out  and  circumcision 
performed.  In  some 
cases  the  penis  is 
adherent  by  its 
under-surface  to  the 
skin  of  the  scrotum 
(webbed  penis.  Fig. 
573),  and  can  be 
freed  by  a  plastic 
operation. 

DOUBLE   PENIS 

This  is  a  rare 
abnormality,  but 
authentic  cases  have 
been  reported.  Both 
penes  may  be  func- 
tional and  void  urine 
and  semen. 

Epispadias  and  hypospadias  are  usually  accompanied  by  deformity  of 
the  penis,  which  in  hypospadias  of  the  complete  and  peno-scrotal  varieties 
is  usually  small,  curved  downwards,  and  fastened  to  the  scrotum  by  bands 
of  skin. 


Fig.  573. — Webbed  penis. 


966  THE    PENIS 

HYPOSPADIAS 

Hypospadias  is  a  congenital  abnormality  of  the  urethra  and  penis 
in  which  the  external  opening  of  the  urethra  is  on  the  under  surface 
of  the  corpus  spongiosum.  It  is  the  result  of  arrested  development 
of  the  penis  occurring  in  early  fee tal  life,  so  that  the  differentiation 
from  the  female  condition  is  not  complete,  and  in  cases  of  complete 
hypospadias  the  diagnosis  of  the  sex  may  be  difficult.  Such  a  con- 
dition is  termed  pseudo-  or  external  hermaphrodism. 

Depending  upon  the  situation  of  the  urethral  orifice  and  the 
amount  of  deformity  of  the  penis,  three  varieties  are  distinguished 
— (1)  hypospadias  of  the  glans  penis,  (2)  penile  and  peno-scrotal 
hypospadias,   (3)  perineo-scrotal  hypospadias. 

1.  Hypospadias  glandis. — This  variety  is  due  to  the  failure  of  the 
invagination  of  the  surface  epithelium  forming  the  urethra  in 
the  glans  to  join  the  genito-urinary  sinus  which  forms  the  urethra 
/n  the  body  of  the  penis.  The  openinu.  which  may  be  double,  is 
situated  just  at  the  attachment  of  the  glans  penis  to  the  body  of  the 
organ.  The  penis  is  usually  well  formed,  and  the  prepuce,  which  -is 
generally  redundant,  forms  a  kind  of  hood  over  the  glans.  If  the 
opening  of  the  urethra  is  sufficiently  large,  the  condition  causes  no 
difficulty  in  coitus  or  micturition. 

2.  Hypospadias  penis. — The  external  opening  of  the  urethra  is  in 
the  body  of  the  penis,  and  usually  at  the  junction  of  the  penis  and 
scrotum  (peno-scrotal  variety).  It  is  due  to  failure  in  development  of 
the  uro-genital  sinus  and  the  corpus  spongiosum.  The  penile  urethra 
is  represented  by  a  moist  red  furrow,  and  the  corpus  spongiosum  by 
two  dense  fibrous  bands  lying  on  either  side  of  the  under  surface  of 
the  penis,  and  representing  the  sides  of  the  original  cloaca.  These 
two  bands  cause  the  penis  to  be  curved  downwards  and  incapable  of 
normal  erection.  The  glans  penis  and  the  corpora  cavernosa  are  usually 
ill  developed.  The  patient  suffers  from  difficulty  in  micturition,  and 
is  unable  to  project  the  stream  beyond  the  scrotum,  which  is  therefore 
liable  to  become  eczematous.  Coitus  is  in  most  cases  incomplete  or 
impossible. 

3.  Hypospadias  perinealis. — This  form  of  hypospadias  is  rare,  and 
is  usually  associated  with  cleft  scrotum  and  Undescended  testes,  making 
differentiation  of  the  sex  difficult  or  even  impossible.  The  opening 
of  the  urethra  is  in  the  perineum  (Fig.  574).  The  penis  and  glans  are  ill 
developed,  the  corpora  cavernosa  being  very  small,  and  the  scrotum 
is  bifid.  Coitus  is  impossible,  and  the  patient  has  to  micturate  in 
the  squatting  position.  There  is  never  incontinence  of  urine  in  any 
degree  of  hypospadias,  as  the  opening  is  always  below  the  constrictor 
urethra\     The  diagnosis  of  the  condition  is  obvious  on  examination. 

Treatment. — Hypospadias   glandis   usually   requires   no    treat- 


HYPOSPADIAS     EPISPAD1  \s 


ment  ;  but  if  the  opening  of  the  urethra  is  too  small  i1  .should  be 
enlarged.  The  condition  is  often  compatible  with  full  Beznal  vigoui 
and  efficiency.  Hypospadias  penis  and  hypospadias  perinealis  are 
unsatisfactory  to  treat,  and  in  many  cases  it  is  probably  best  to  leave 
the  condition  untreated.  Manx-  plastic  operations  have  been  devised, 
hut  tlu'  -patient  is  rarely  satisfied  with  the  results  oi  any  ot  them. 
it  i-  probably  besl  to  defer  operation  till  puberty,  or  till  the  patient 
can  take  an  intelligent  interesl  in  his  cure  and  give  all  the  help  in 
his  power  to  thf  after-tri 
ment.  Several  operations  are 
necessary  in  severe  cases,  and 
not  too  much  should  be  at- 
tempted at  one  time.  The 
penis  should  first  be  freed  from 
the  two  fibrous  bands  which 
cause  its  downward  curve,  and 
an  attempt  then  made  to  form 
a  urethra 

EPISPADIAS 

Epispadias  is  a  congenital 
abnormality  of  the  urethra 
and  penis  in  which  the  penis 
is  cleft  above  and  the  urethra 
opens  on  the  upper  surface. 
Like  hypospadias  it  may  be 
divided  into  three  degrees, 
according  to  the  position  of 
the  opening — (1)  The  opening 
is  just  behind  the  glans  ;  (2) 
the  opening  is  on  the  body 
of  the  penis  ;  (3)  the  cleft 
extends  the  whole  length  of  the  penis,  and  is  frequently  complicated 
by  ectopia  vesica?.     The  third  degree  is  by  far  the  most   common. 

In  the  first  two  degrees  the  corpora  cavernosa  are  present,  and 
the  penis  is  short  but  large,  with  a  tendency  to  turn  upwards ;  but  in 
the  third  degree  the  penis  is  stunted  and  practically  represented  by 
the  glans.  while  the  corpora  cavernosa  are  very  defective. 

Cleft  scrotum,  imperfectly  descended  testis,  congenital  hernia,  non- 
union of  the  symphysis  pubis,  and  ectopia  vesicas  are  frequently  present 
in  association  with  the  third  degree  of  epispadias. 

It  is  difficult  to  explain  this  deformity,  but  the  explanation  which 
appears  to  be  most  in  accordance  with  facts  is  that  the  condition 
is    really    one    of   hypospadias    in  which    torsion    of   the    penis    has 


1 

\ 

Bfej^H 

^^Sft^r  - 

Hi 

Fig.  574. — Hypospadias  perinealis  (ex- 
ternal psevdo-hermaphrodism"). 


968  THE   PENIS 

occurred  at  an  early  age  of  foetal  life  so  that  the  under  surface 
becomes  the  upper. 

Symptoms. — In  the  common  form  with  complete  cleft  of  the 
penis  the  chief  trouble  is  the  dribbling  incontinence  of  urine  which 
occurs  owing  to  the  division  of  the  sphincter  muscles.  This  leads  to 
eczema  of  the  surrounding  parts  and  the  usual  miserable  condition 
of  patients  suffering  from  urinary  incontinence.  Coitus  is  difficult 
or  impossible. 

Treatment. — The  treatment  of  epispadias  consists  either  in 
uniting  the  edges  of  the  fissure  of  the  urethra  or  in  performing  plastic 
operations.  The  same  difficulties  are  present  as  in  hypospadias,  but 
after  several  attempts  it  may  be  possible  to  get  a  fairly  satisfactory 
result.  Incontinence  of  urine  will  continue  in  cases  of  complete 
epispadias,  however  satisfactory  a  penis  may  be  formed. 

HEKMAPHKODISM 

This  subject  may  be  conveniently  discussed  here,  owing  to  its  close 
association  with  malformations  of  the  penis. 

The  only  true  criterion  of  sex  is  the  structure  of  the  genital  gland, 
the  male  gland  producing  spermatozoa  and  the  female  ova.  A  true 
hermaphrodite,  therefore,  would  be  an  individual  who  possessed  both 
kinds  of  genital  glands,  an  ovary  and  a  testis  on  either  side,  or  two  of 
each  kind.  Such  an  individual  has  never  been  known  to  survive 
birth,  even  if  the  condition  has  occurred  amongst  prenatal  monsters, 
which  is  doubtful.  Cases  of  true  hermaphrodism  are  reported  from 
time  to  time,  but  the  descriptions  are  always  lacking  in  essential 
details,  and  the  only  true  scientific  proof  would  be  obtained  from 
microscopic  sections  of  the  genital  glands.  True  hermaphrodism 
therefore  probably  does  not  exist  in  human  subjects. 

PSEUDO-HERMAPHRODISM 

In  early  foetal  life  there  is  no  distinction  between  the  sexes  either 
in  the  internal  or  in  the  external  sexual  organs,  and  rudiments  of  the 
sexual  apparatus  of  the  opposite  sex  persist  in  all  individuals  through- 
out life.  In  the  external  organs  the  male  genitals  are  merely  a  further 
development  of  the  female.  The  penis  is  a  large  clitoris  enclosing 
the  urethra,  the  scrotum  the  coalescence  of  the  labia  majora,  while 
the  descent  of  the  testes  is  frequently  simulated  by  the  descent  of  the 
ovaries  into  the  sacs  of  inguinal  hernise.  The  female  breast  is  repre 
sented  by  the  rudimentary,  functionless  male  breast.  In  the  internal 
organs  of  generation,  the  male  retains  in  the  uterus  masculinus  the 
representation  of  the  uterus,  Fallopian  tubes,  and  vagina  of  the  female, 
both  being  developed  from  Midler's  duct ;  whilst  in  the  female  the  duct 
of  Gartner  represents  the  vas  deferens,  both  having  their  origin  in 
the  Wolffian  duct. 


I'SIU  nO-HKRMAIMIROniSM  969 

It  is    not,   therefore,   surprising  that   individuals   are    me1    with 

in  whom  the  rudiments  of  the  sexual  apparatus  of  the  opposite  sex 
become  more  developed  than  normal,  and  a  condition  results  in  which 
it  is  not  easy  to  determine  the  sex  of  the  patient  without  micro- 
scopical examination  of  the  genital  gland.  Such  an  individual  is 
termed  a  pseudo-hermaphrodite,  and  two  varieties,  external  and 
internal,  are  differentiated,  according  as  the  internal  or  the  external 
genital  glands  are  chiefly  or  wholly  affected. 

Careful  examination  in  recent  years  of  these  pseudo-hermaphrodites 
has  shown  that  about  95  per  cent,  of  them  possess  testes,  and  are 
therefore  males.  It  might  be  expected  that  at  puberty  the  sexual 
instincts  of  the  pseudo-hermaphrodite  would  indicate  the  sex,  but 
this  is  not  always  so,  and  instances  are  known  of  individuals  with 
congenital  abnormality  of  the  external  sexual  apparatus  living  happily 
as  married  women  although  microscopical  examination  of  the  genital 
gland  has  revealed  the  presence  of  spermatozoa. 

Internal  Pseudo-Hermaphrodism 
In  these  cases  the  external  organs  of  generation  are  normal  and 
well  developed,  the  secondary  sexual  characters — breast,  distribution 
of  pubic  hair,  and  voice — are  of  the  normal  type,  but  the  individual 
possesses  a  large  uterus  and  Fallopian  tubes.  The  condition  is  only 
discovered  during  operation  or  post-mortem  examination.  The  reason 
for  operation  is  frequently  the  presence  of  an  inguinal  hernia,  in  the 
sac  of  which  the  uterus  is  found,  having  been  dragged  there  by  the 
descent  of  the  testis,  wThich  in  these  cases  is  attached  to  the  uterus. 
In  such  individuals  imperfect  descent  of  the  testes  is  common. 

Treatment. — It  is  only  when  the  uterus  is  found  in  the  sac  of 
an  inguinal  hernia  that  treatment  is  required  ;  then  the  uterus  should 
be  removed,  and  the  canal  closed  as  in  the  usual  radical  cure. 

External  Pseudo-Hermaphrodism 
In  the  course  of  development  of  the  external  genitalia  the  male 
passes  through  a  stage  which  closely  resembles  the  female.  The  testes 
are  not  yet  descended,  the  folds  of  the  scrotum  have  not  formed,  and 
the  penis  is  represented  by  the  small  genital  eminence.  Arrest  of 
development  at  this  stage  will  give  rise  to  an  individual  with  external 
genitalia  resembling  those  of  the  female,  although  the  genital  glands  are 
testes.  The  opposite  condition,  in  which  in  an  individual  with  ovaries 
the  development  continues  till  the  male  external  organs  are  formed, 
is  unknown,  although  cases  of  hypertrophy  of  the  clitoris  are  recog- 
nized. The  testes  not  infrequently  descend  later,  and  are  sometimes 
removed  during  an  operation  for  supposed  hernia,  and  the  sex  of 
the  patient  becomes  recognized  on  microscopical  examination  of  the 
genital  gland. 


970  THE    PENIS 

Patients  with  external  pseudo-hermaphrodism  therefore  resemble 
females,  and  are  often  named  and  educated  as  girls ;  but,  in  view  of 
the  fact  that  95  per  cent,  of  all  pseudo-hermaphrodites  are  males,  the 
patients  should  always  be  educated  and  treated  as  boy.-. 

External  pseudo-hermaphrodism  is  sometimes  complicated  with 
ectopia  vesicae. 

The  condition  of  the  secondary  sexual  characters  in  these  patients 
and  their  sexual  instincts  vary.  In  some  cases  the  secondary  character- 
istics are  undoubtedly  masculine,  and  no  doubt  of  the  sex  exists  after 
puberty  ;  but  in  others  the  secondary  characters  which  in  the  human 
race  are  almost  confined  to  the  male  do  not  develop,  and  the  sexual 
instincts  may  be  so  perverted  that  the  patient,  although  a  male  with 
testes,  may  live  happily  as  a  married  woman.  Determination  of  the 
sex  may  be  impossible  in  some  cases  without  microscopical  examina- 
tion of  the  genital  gland. 

The  psychology  of  these  patients  is  important  from  the  medico- 
legal standpoint,  and  the  condition  may  account  for  some  cases  of 
sexual  coldness  or  perverted  sexual  instincts  met  with  in  apparent 
females  who  are  really  males. 

Fortunately,  pseudo-hermaphrodites  are  usually  sterile,  either  from 
obvious  reasons  or  because  the  undescended  testes  are  malformed  and 
non-functional. 

PHIMOI> 

In  phimosis  the  prepuce  cannot  be  retracted  freely  over  the  glans 
owing  to  its  length,  to  smallness  of  its  opening,  or  to  adhesions. 
These  conditions  are  frequently  combined,  and  the  phimosis  may  be 
either  congenital  or  acquired. 

Congenital  Phimo-.i~ 

In  the  newly-born  infant  the  prepuce  is  normally  slightly  adherent 
to  the  glans  penis,  but  these  adhesions  disappear  as  the  clrild  gets  older, 
so  that  inability  completely  to  retract  the  prepuce  in  the  newly  bom 
should  not  be  called  phimosis  and  does  not  necessarily  call  for  circum- 
cision. Apart  from  complications,  circumcision  is  necessary — (a)  if 
the  preputial  orifice  is  so  small  that  the  end  of  the  glans  and  the  orifice 
of  the  urethra  cannot  be  easily  uncovered  ;  (b)  if  the  prepuce  is  long 
and  projects  well  beyond  the  glans  (this  may  be  associated  with 
a  narrow  preputial  orifice  or  not)  ;  (c)  if  the  prepuce  is  closely  adherent 
to  the  whole  of  the  glans  penis  ;  (d)  if,  although  the  prepuce  can  be 
retracted  behind  the  corona,  there  is  difficulty  in  getting  it  back — in 
other  words,  if  there  is  a  tendency  to  paraphimosis. 

Symptoms. — Children  with  phimosis  are  brought  to  the  surgeon 
for  two  reasons — because  the  parents  think  that  circumcision  is 
required,  or  because  some  complication  has  arisen. 


PHIMOSIS  97r 

Complications.    Tin    complications  of  phimosis  are — 

((/)  Difficulty  and  pain  on  passing  urine. 

(//)   Retention  oi  urine,  with  its  sequelse  on  the  bladder,  ureti 
;iikI  kidneys. 

(c)  Incontinence  oi  urine. 

((/)  Retention   of  secretion    or   formation   of   calculi   under   the 
prepuce. 

(.)   [nflammatory  conditions.     Balano-posthitis. 

{f)  Hernia  or  prolapsus  ani,  due  to  Btraining. 

[g)  Sexual  excitement.     Masturbation  and  its  effects. 

(/*)  Difficulties  in  coitus. 

(/)  Paraphimosis. 

(j)  Malignant  disease. 
An  important  associated  condition  which  Bhould  always  be  looked 
for,  and.  if  found,  treated  when  circumcision  is  performed,  is  .1  small 
(pin-hole)  urinary  meatus.     If  this  condition  is  overlooked,  difficulty 
of  micturition  may  continue  after  the  operation. 

Treatment. — Cases  in  which  the  prepuce  in  a  child  cannot  be 
freely  retracted  owing  to  slight  adhesions  between  the  prepuce  and 
the  glans  should  be  treated  by  separating  the  adhesions  with  a  probe, 
retracting  the  prepuce,  and  smearing  the  glans  with  vaseline.  Retrac- 
tion should  then  be  practised  daily  till  the  prepuce  retracts  easily 
and  without  pain.  These  cases  are  the  exception  ;  all  other  cases  of 
congenital  phimosis  should  be  treated  by  circumcision  unless  surgical 
interference  is  contra-indicated  by  some  disease,  e.g.  hemophilia. 

In  doing  the  operation  care  must  be  taken  to  remove  a  sufficiency 
of  both  layers  of  the  prepuce,  otherwise  the  condition  will  not  be 
remedied  :  but  at  the  same  time  too  much  should  not  be  removed. 
When  the  wound  has  healed,  the  corona  glandis  should  be  covered. 
The  operation  in  adults  can  be  readily  performed  under  local  anaesthesia. 

A,<  quired  Phimosis 

Acquired  phimosis  may  be  transitory  or  permanent,  and  the  former 
may  pass  into  the  latter. 

Transitory  acquired  phimosis  is  due  to  inflammatory  conditions  of 
the  prepuce  or  glans,  such  as  soft  sores,  hard  chancres,  balano-posthitis 
of  gonorrhoea,  septic  sores,  etc.  In  these  conditions  the  inflammatory 
cedema  of  the  prepuce  prevents  retraction.  The  treatment  is  cleanliness 
and  relief  of  the  primary  affection.  The  patient  should  sir  in  hot 
baths,  syringe  with  hot  weak  antiseptic  lotion  under  the  prepuce,  and 
endeavour  to  retract  it  so  that  it  may  be  thoroughly  cleaned.  If  it  is 
found  impossible  to  secure  freedom  from  foul  secretion,  the  prepuce 
should  without  delay  be  freely  slit  up  dorsally  as  far  as  the  corona  in 
order  to  avoid  sloughina  and  to  establish  an  exact  diagnosis. 


972  THE   PENIS 

Permanent  acquired  phimosis  is  the  result  of  inflammatory  lesions 
ending  in  the  formation  of  sear  tissue,  such  as  the  healing  of  ulcers 
and  chancres,  or  fibrosis  supervening  on  a  chronic  balano-posthitis. 
The  condition  is  of  special  importance  in  elderly  men,  as  it  may  pre- 
dispose to  carcinoma,  and  it  will  be  more  fully  dealt  with  in  considering 
malignant  diseases  of  the  penis. 

PARAPHIMOSIS 

This  term  indicates  inability  to  draw  the  prepuce  forward  again 
after  it  has  been  retracted  behind  the  glans  penis.  It  is  always 
associated  with  phimosis,  which  may  be  congenital  or  the  result  of 
an  inflammatory  condition  of  the  prepuce  or  glans  penis. 

Acute  paraphimosis  is  frequently  seen  in  boys  and  young  men 
who  have  retracted  a  tight  prepuce  from  curiosity  or  when  mas- 
turbating, but  is  also  common  after  coitus  or  as  a  complication  of 
chancre  or  gonorrhoea.  The  condition  is  usually  recognized  at  a  glance. 
The  glans  penis  is  swollen  and  congested,  and  behind  the  corona  is  a 
red  cedematous  roll  of  tissue,  most  marked  underneath,  which  represents 
the  returning  layer  of  the  prepuce.  Behind  this  is  a  deep  sulcus 
which  corresponds  to  the  narrow  preputial  orifice,  and  behind  this 
again  is  a  second  cedematous  collar  of  skin  corresponding  to  the  outer 
layer  of  the  prepuce.  The  whole  penis  is  swollen  and  congested,  and 
frequently  twisted.  If  the  condition  is  not  treated,  ulceration  of  the 
constricting  band  formed  by  the  preputial  orifice  takes  place,  and  the 
congestion  is  relieved,  but  the  paraphimosis  may  become  permanent. 
Very  rarely  sloughing  of  the  glans  penis  may  occur. 

Treatment. — Treatment  consists  in  immediate  reduction.  In 
order  to  reduce  the  swelling  the  penis  is  bandaged  firmly  from  the  glans 
backwards  with  a  cold-water  bandage.  The  bandage  is  left  in  position 
for  a  few  minutes  and  then  removed.  The  penis  is  then  grasped  between 
the  index  and  middle  fingers  of  both  hands  while  the  thumbs  rest 
on  the  glans.  A  combination  of  steady  pulling  forwards  with  the 
fingers  and  pushing  backwards  with  the  thumbs  will  usually  effect 
reduction.  When  the  oedema  has  disappeared  circumcision  should 
be  advised.  If  reduction  is  not  accomplished  in  this  way,  the  con- 
stricting band  should  be  cut  across  without  delay ;  reduction  is 
then  easy. 

Chronic  paraphimosis  is  an  occasional  sequel  to  acute  para- 
phimosis with  moderate  constriction,  or  the  condition  may  be  chronic 
from  the  first  and  due  to  inflammation.     It  is  rare. 

Treatment. — Inflammatory  conditions  should  be  treated  on 
general  principles,  but  if  the  condition  is  permanent  from  organization 
of  the  exudate,  as  in  a  case  under  my  care,  a  plastic  operation  may  be 
considered  advisable. 


INJURIES  TO  THE   PENIS  973 

CALCULI    UNDER    THE    PREPUCE 

Preputial  calculi  are  rare,  and  are  onTj  found  in  association  with  marked 
degrees  of  phimosis.  Thej  maj  be  Bingle  or  multiple,  and  have  been  known 
to  reacb  the  size  of  a  man's  fist.  They  arise  in  three  ways:  (a)  deposits  of 
lime  ^alt^  in  retained  smegma;  (5)  deposits  of  urinarj  Baits,  ohiefly  phos- 
phates from  decomposing  urine  retained  under  a  long  prepuce;  (c)  bladder- 
stones  which  have  passed  along  the  urethra  and  are  there  retained  by  the 
phimosed  prepuce.  The  oondition  gives  rise  to  a  purulent  discharge  from 
the  prepuce,  and  the  diagnosis  is  readily  made  by  examination. 

Treatment  consists  in  slitting  up  the  prepuce,  removing  the  calculi, 
and  then  circumcising  the  patient. 

SHORTNESS    AND    RUPTURE    OF   THE   FRyENl  .M 

This  is  usually  of  little  importance,  but  the  frsonum  maybe  so  short 
that  the  dans  penis  curves  downwards  during  erection,  and  so  renders 
coitus  painful.  Of  more  importance  is  rupture  of  the  frsenum,  a  not 
infrequent  accident  during  coitus,  which  may  lead  to  severe  haemor- 
rhage, and  the  small  wound  is  liable  to  venereal  infection. 

Treatment. — If  the  frsenum  is  so  short  as  to  interfere  with 
coitus,  it  should  be  divided  and  the  artery  secured. 

INJURIES  TO  THE  PENIS 

Contusion  of  the  penis  is  an  uncommon  accident,  and  usually 
occurs  during  erection.  It  may  be  due  either  to  violent  attempts  at 
coitus,  or  to  acts  of  resistance  or  revenge  on  the  part  of  the  woman. 
In  some  cases  the  sheaths  of  the  corpora  cavernosa  are  ruptured, 
causing  so-called  fracture  of  the  'penis.  In  the  graver  injuries  there  is 
severe  pain,  followed  by  great  swelling  of  the  organ  due  to  extravasated 
blood,  and  the  urethra  is  usually  injured  at  the  same  time.  Retention 
of  urine  is  a  common  consequence. 

Treatment. — In  the  slighter  injuries  the  treatment  consists  in 
wrapping  the  penis  in  evaporating  lead  lotion  and  waiting  for  the 
absorption  of  the  extravasated  blood.  If  the  penis  is  fractured,  with 
laceration  of  the  urethra,  the  treatment  is  operative.  The  wounded 
part  should  be  freely  laid  open,  the  lacerated  urethra  sutured,  all  blood 
clots  removed,  and  the  sheaths  of  the  corpora  cavernosa  sutured. 

In  some  cases  contusion  of  the  penis  is  followed  by  alteration  in 
the  normal  erection  of  the  penis.  The  part  in  front  of  the  fracture 
remains  flaccid,  whilst  the  posterior  end  is  rigid.  This  condition  is 
due  to  the  fibrosis  that  has  occurred  in  the  corpora  cavernosa  in  the 
healing  of  the  lesion.  This  serious  result  is  best  prevented  by  careful 
suturing  at  the  time  of  the  accident. 

DISLOCATION    OF    THE   PENIS 

In  this  rare  accident  the  prepuce  is  torn  away  from  its  attachment 
to  the  dans  penis,  and  the  penis  itself  with  the  glans  is  dislocated  into 


I 


974  THE   PENIS 

the   subcutaneous   tissue   of  the   groin,   abdomen,   or   scrotum.     The 
skin  of  the  penis  hangs  down  empty  in  its  usual  position. 

Treatment. — The  -wound  must  be  freely  opened  up  so  as  to  arrest 
all  hemorrhage,  and  the  penis  brought  back  into  position  and  sutured. 
Laceration  of  the  urethra  should  always  be  examined  for  and  appro- 
priately treated. 

CONSTRICTING  BODIES 

Constriction  of  the  penis  by  thread,  string,  rings,  and  other  foreign 
bodies  is  not  infrequent.  The  constricting  band  is  either  placed  round 
the  penis  to  satisfy  morbid  sexual  impulses,  or  in  children  and  young 
adults  to  prevent  nocturnal  enuresis  or  emissions.  In  a  few  cases  it 
is  a  form  of  practical  joke  of  the  patient's  companions. 

The  penis  in  front  of  the  constricting  band  becomes  swollen,  con 
gested,  and  oedematous,  so  that  the  band  cannot  be  removed,  and  in 
a  few  cases  gangrene  results.     The  swelling  may  be  so  severe  that  the 
constricting  band  is  completely  hidden,  and  the  diagnosis  can  only  be 
made  by  the  history  and  the  swelling. 

Treatment. — In  most  cases  an  anaesthetic  is  necessary,  and  the 
band  is  then  removed  as  ingenuity  suggests.  The  use  of  a  director 
and  a  Gigli  saw  is  sometimes  necessary  for  the  division  of  metal  rings. 

NEW  GROWTHS  OF  THE  PENIS 

INNOCENT    GROWTHS 

Angiomas  (naevi)  of  the  penis  have  been  described,  but  are  rare,  the 
only  common  innocent  growths  of  the  penis  being  papillomas. 

Papilloma 

Warts  of  the  penis  may  be  divided  into  hard  and  soft  varieties. 

Hard  papillomas  are  usually  single,  and  are  less  common  than  the 
soft  variety.  They  resemble  warts  in  other  parts  of  the  body,  and  if 
left  untreated  or  irritated  may  become  carcinomatous.  In  some  cases 
a  horny  growth  develops  in  them,  and  horns  of  several  inches  in  length 
have  been  described.  In  elderly  men,  hard  warty  growths  should  be 
looked  upon  with  suspicion  as  the  commonest  starting-point  of  car- 
cinoma of  the  penis.  The  growth  should  be  carefully  microscoped 
after  complete  removal. 

Soft  papillomas  are  frequently  associated  with  venereal  disease 
or  retained  secretion  from  phimosis,  but  may  occur  independently  of 
cither  of  these  two  causes.  They  are  usually  found  in  the  sulcus 
behind  the  corona,  or  on  the  glans,  are  multiple,  bleed  readily,  and 
have  a  foul  secretion.  They  may  be  either  pedunculated  or  sessile, 
and  there  is  frequently  associated  enlargement  of  the  inguinal  glands. 

Treatment. — Papillomas  both  of  the  hard  and  of  the  soft  variety 


CARCINOMA   OF   THE    PENIS  075 

should  be  removed  with  scissors  and  theii  bases  cauterized.  Absolute 
cleanliness  and  the  careful  fcreatmenl  ->f  any  accompanying  venereal 
disease  are  necessary  to  prevent  their  recurrence. 

Horns 

On  the  penis  may  arise  in  connexion  with  suppurating  sebaceous  cyste  or 
papillomas.  They  are  rare,  bul  the  diagnosis  is  obvious.  Ulceration  progressing 
to  carcinoma  may  occur  at  the  base  of  a  horn.  The  treatment  i-  complete 
removal. 

M  JJLIGNANT   GBOWTHS 

I  JABCINOMA 

This,  the  common  form  of  malignant  growth  affecting  the  penis, 
may  occur  in  one  of  two  varieties.  The  more  common  is  a  Bquamous- 
celled  carcinoma  arising  from  the  superficial  epithelium,  the  other 
variety  being  a  glandular  carcinoma  springing  from  the  few  glands 
that  are  found  near  the  corona,  the  glands  of  Tyson.  The  latter 
variety  is  said  to  be  more  malignant  than  the  former. 

Etiology. — The  disease  is  rare  before  the  age  of  40,  most  cases 
being  seen  in  men  of  50  to  70,  and  usually  nearer  the  latter  age.  It  is 
predisposed  to  by  phimosis,  congenital  or  acquired,  want  of  cleanliness, 
venereal  sores,  papillomas  and  gummata  of  the  penis.  There  is  also 
a  precancerous  condition  similar  to  that  met  with  in  the  tongue,  and 
called  eczema  of  the  glans,  Paget's  disease  of  the  penis,  and  leucoplakia, 
but  which  is  really  a  chronic  superficial  inflammation  of  the  glans  penis 
and  under-surface  of  the  prepuce.  This  disease  occurs  in  elderly  men, 
and  leads  to  acquired  phimosis,  with  a  tendency  to  hemorrhage  if 
the  prepuce  is  forcibly  retracted.  The  condition  is  recognized  by 
white  patches  (leucoplakia),  which  are  found  on  the  under-surface  of 
the  prepuce  and  on  the  glans  penis,  resembling  the  white  patches 
of  the  tongue  in  chronic  superficial  glossitis.  Raw  red  patches  with 
a  tendency  to  bleed  may  also  be  present.  Carcinoma  usually  develops 
if  the  condition  is  neglected. 

Pathological  anatomy  and  clinical  features. — Car- 
cinoma of  the  penis  usually  starts  as  a  warty  growth  on  or  just 
behind  the  glans  penis.  (Figs.  575,  576.)  The  growth  has  the  usual 
indurated  base  and  spreads  rapidly  over  the  glans,  but  ulceration 
does  not  occur  early.  The  growth  is  at  first  limited  to  the  surface 
of  the  penis  by  the  fibrous  capsules  of  the  corpora  cavernosa  and 
the  corpus  spongiosum,  but  when  it  invades  these  it  grows  with 
great  rapidity,  destroying  their  structure  and  often  enlarging  tin- 
penis  to  three  or  four  times  its  usual  size.  The  urethra  is  not  in- 
volved as  a  rule,  and  there  is  no  obstruction  to  the  passage  of 
urine,  but  ulceration  may  occur  behind  the  growth  and  a  urinary 
fistula  develop.      (Fig.  577.)      When    ulceration    occurs    the    growth 


976 


THE   PENIS 


presents  the  usual  characters  of  a  carcinomatous  ulcer,  with  a  hard 
indurated  base  and    a    foul   secretion.     (Fig.  578.)     The  glands  first 

to  be  infected  are 
the  inguinal  glands, 
usually  on  both  sides, 
but  with  involvement 
of  the  body  of  the 
penis  the  lumbar 
glands  may  show 
secondary  growths. 
Metastases  in  other 
organs  are  rare.  Pain, 
and  even  inconveni- 
ence, are  absent  in 
the  early  stages,  ac- 
counting for  the  'ad- 
vanced condition  in 
^Jtvvv    ^      Vr  which     the     surgeon 

usually  first  sees  the 
disease. 

In  the  early  diag- 
nosis it  is  important 
to  remember  that  a 
carcinoma  may  be  growing  unseen  behind  a  tight  prepuce ;  and  in 
every  case  in  an  elderly  man,  where  a  discharge  is  present  or  an 
induration  can  be  felt  under  a  phimosed  prepuce,  circumcision  should 

be  strongly 
urged  with  a 
view  to  ascer- 
taining the  exact 
condition  of  the 
glans. 

The  condi- 
tion which  most 
closelyresembles 
carcinoma  of  the 
penis  is  syphil- 
itic ulceration, 
which  not  infre- 
quently occurs 
in  the  old  scar 
of  a  primary 
576. — Section  through  the  same  penis  as  in  chancre,  and  in 
Fig.  575.  some   cases   the 


Fig.  575. — Glans  penis  with  carcinoma  of  the 
warty  type. 


CARCINOMA   OF   THE    PENIS 


977 


diagnoM-  is  only  established  by  the  effects  ol  treatment  oz  by  micro- 
scopical examination  of  a  small  portion  of  the  diseased  ti-^ue. 


Fig.  .377. — Longitudinal  section  of  a  penis  with  advanced  carcinoma, 
showing  the  formation  of  a  fistula. 

Treatment. — The  only  treatment  for  carcinoma  of  the  penis  is 
early  removal  of  the  growth  with  a  wide  margin  of  healthy  tissue,  and 


Fig.  578. — Lateral  view  of  a  penis  with  a  carcinoma  fungating 
through  the  skin. 

removal  of  both  sets  of  inguinal  glands  on  the  two  sides  of  the  body. 
If  the  disease  is  limited  to  the  dans,  and  the  penis  is  sufficiently  long 
3  k 


978  THE    PENIS 

partial  amputation  with  removal  of  the  inguinal  glands  is  all  that  is 
necessary ;  but  with  more  extensive  disease,  and  in  any  case  of  doubt 
as  to  getting  clear  of  the  disease,  the  whole  penis  should  be  removed, 
the  crura  being  detached  from  the  arch  of  the  pubes.  The  urethra  is 
then  brought  out  into  the  perineum  and  fixed  just  in  front  of  the  anus. 
It  is  advisable,  if  this  operation  is  done,  to  remove  the  testes  at  the 
same  time,  as  this  makes  micturition  more  comfortable  and  prevents 
excoriation  and  eczema  of  the  scrotum.  Removal  of  the  testes,  however, 
adds  to  the  gravity  of  the  operation,  which  has  frequently  to  be  done 
in  very  elderly  people  debilitated  by  septic  absorption  and  a  fetid 
discharge.  The  most  difficult  part  of  the  operative  treatment  is  the 
thorough  removal  of  all  the  inguinal  glands,  and  not  infrequently  part 
of  the  femoral  vein  must  be  excised  to  make  the  operation  complete. 
Prognosis. — If  the  case  is  seen  early  and  a  thorough  operation 
is  done,  the  prognosis  is  fair,  as  metastases  in  distant  organs  are 
unusual ;  but  the  cases  are  rarely  seen  very  early,  as  the  condition 
causes  so  little  pain  and  discomfort. 

Sarcoma 

This  condition,  which  may  be  either  primary  or  secondary,  is  rare. 
In  the  primary  cases  the  growth,  which  is  most  often  a  spindle-celled 
sarcoma,  usually  springs  from  the  fibrous  sheaths  of  the  corpora 
cavernosa,  and  is  confined  to  them  for  a  long  time.  The  penis 
becomes  hard  and  swollen,  and  often  very  painful,  whilst  interference 
with  micturition  or  a  blood-stained  discharge  from  the  urethra  may 
occur. 

The  only  treatment  is  early  amputation,  with  removal  of  the 
glands  in  both  groins. 

OTHER  CONDITIONS  OF  THE  PENIS 
HERPES 

Both  catarrhal  herpes  and  herpes  zoster  may  attack  the  penis,  the 
former  being  by  far  the  more  common  disease. 

Herpes  zoster  may  follow  the  course  of  the  ilio-inguinal  nerve,  and 
does  not  differ  in  its  course  and  symptomatology  from  herpes  zoster 
in  other  parts  of  the  body.  It  is  extremely  rare  in  the  penis.  Catarrhal 
herpes  is  chiefly  seen  in  the  prepuce  and  glans  penis  (herpes  progeni talis), 
and  the  exact  cause  is  unknown.  It  has  been  attributed  to  syphilis, 
other  venereal  infections,  sexual  excess,  gout,  and  other  causes,  but 
without  much  evidence.  The  disease  usually  appears  shortly  after 
coitus  or  nocturnal  emissions. 

Symptoms. — The  patient  first  complains  of  an  itching  or  burning 
sensation  on  the  prepuce  or  glans  penis,  and  a  patch  of  erythema 


PRIAPISM 

appears  at  the  spot.  < >n  this  patch  of  erythema  appeal  a  group  <»f 
small  vesicles  which  soon  burst,  Leaving  small  ulcers  thai  rapidly 
heal.  The  affection  usually  runs  its  entire  course  in  a  week-.  In  most 
cases  the  pain  is  trifling,  bu1  it  may  be  severe  (neuralgic  herpes). 

Prognosis.  The  condition  rapidly  gets  well,  but  recurrence  is 
common,  and  the  excoriated  surface  may  be  infected  by  the  SpifO' 
ckcBte  pallida  or  other  organism  it  the  patient  is  exposed  to  infection. 

Treatment.  Local  cleanliness  is  all  that  is  ueeded,  but  no 
measures  can  be  absolutely  relied  upon  to  prevent  recurrence.  Arsenic 
has  been  strongly  recommended.  Even  if  the  disease  is  limited  to 
the  prepuce,  circumcision  may  fail  to  cure,  as  the  disease  may  reappear 
on  the  glans  penis. 

PRIAPISM 

When  this  condition  is  pathological  there  is  continued  erection 
of  the  penis,  often  accompanied  by  severe  pain,  without  sexual  desire. 
The  condition  is  rare,  and  usually  only  affects  the  corpora  cavernosa, 
the  corpus  spongiosum  being,  as  a  rule,  unaffected.  The  causes 
are  said  to  be  excessive  coitus,  injury,  alcoholism,  leukaemia,  gout, 
and  irritation  from  -worms  or  a  tight  prepuce.  In  fracture  of  tin- 
lower  cervical  or  upper  dorsal  portion  of  the  spine,  with  injury  to 
the  cord,  the  penis  is  often  turgid  but  without  rigidity. 

Symptoms. — The  penis  is  turgid  and  erect,  tender  and  very  pain- 
ful. Micturition  may  be  interfered  with,  but  this  is  not  usual.  The 
duration  of  the  priapism  varies,  but  it  may  last  for  weeks. 

Treatment  is  unsatisfactory,  but  the  drug  that  has  been  used 
with  most  success  is  bromide  of  potassium,  whilst  morphia  may  be 
necessary  on  account  of  the  pain.  Incision  of  the  penis  has  been  tried 
in  some  cases  with  success,  and  under  proper  precautions  should  be 
given  an  early  trial  if  bromides  fail. 

THE   SCROTUM 
ACUTE   SEPTIC  INFECTION   (CELLULITIS) 

Acute  septic  infection  of  the  scrotal  tissues  does  not  differ  in  cause 
or  course  from  a  similar  infection  of  the  skin  or  subcutaneous  tissue  in 
other  parts  of  the  body.  Locally  it  is  characterized  by  excessive  swell- 
ing of  the  scrotum,  and  its  tendency  is  to  end  in  gangrene,  especially 
of  the  anterior  part  of  the  scrotum,  so  that  the  testes  are  exposed.  The 
general  symptoms  are  those  of  acute  sepsis. 

Treatment. — At  first  the  scrotum  should  be  supported  and 
warmth  applied  by  means  of  fomentations.  If  the  swelling  does  not 
quickly  subside,  free  long  incisions  on  each  side  of  the  median  raphe 
should  be  made,  goinc  through  the  dartos.     These  incisions  should  be 


qSo  the  scrotum 

allowed  to  gape  widely  and  bleed  freely.  Afterward-  the  patient 
should  sit  in  a  hot  bath  for  several  hours  a  day.  and  in  the  intervals 
fomentations  should  be  applied.  If  sloughing  occur,  the  treatment 
should  be  continued,  and  it  will  always  be  found  that  the  testicles 
are  covered  without  the  need  of  skin  grafts. 

MALIGNANT    GROWTHS 

Two  forms  of  malignant  growth  are  met  with  in  the  scrotum, 
squaruous-eelled  carcinoma  (epithelioma)  and  melanotic  sarcoma,  the 
former  being  by  far  the  more  common. 

Squamous-Celled  Carcinoma — 
"  Chimney-sweep's  cancer " — has  the  same  structure  and  clinical 
course  as  similar  growths  on  other  parts  of  the  skin.  It  occurs  most 
frequently  in  men  engaged  in  occupations  in  which  it  is  difficult  to 
keep  the  skin  clean,  such  as  cliimney-sweeps,  tar.  gas,  and  paraffin 
workers.  Not  infrequently  the  disease  shows  two  distinct  stages.  At 
first  there  is  a  soft  warty  growth  of  innocent  nature,  which  may  grow 
for  a  time  and  then  easily  be  knocked  off,  leaving  a  pigmented  eczenia- 
tous  patch  (tar-worker's  molluscum  and  tar-worker's  eczema).  The 
disease  may  remain  for  a  long  time  at  this  stage,  but  sooner  or  later 
ulceration  takes  place,  and  the  well-known  characters  of  a  squamous- 
celled  carcinomatous  ideer  appear.  The  disease  may  also  start  as 
a  papillomatous  growth,  or  as  a  small  subcuticular  nodule,  as  in 
other  parts  of  the  skin. 

The  inguinal  glands  become  enlarged  at  first  by  inflammation,  but 
later  they  are  invaded  by  the  malignant  growth,  and  become  hard, 
matted,  and  fixed.  The  disease  is  limited  for  a  long  time  to  the  scrotum 
and  inguinal  glands,  and  metastases  in  other  organs  are  uncommon. 
The  neoplasm  is,  as  a  rule,  of  very  slow  growth,  and  the  patient  may 
have  given  up  the  dangerous  occupation  for  some  years  before  it  appears, 
but  microscopic  examination  of  the  skin  of  the  scrotum  of  a  sweep  will 
usually  reveal  soot  in  the  cells  which  no  amount  of  washing  will  remove. 

Treatment. — Prophylactic  treatment  consists  of  the  exercise  of 
great  cleanliness  by  people  engaged  in  the  dangerous  trades,  and  the 
thorough  removal  of  all  papillomatous  growths  as  soon  as  they  appear. 
If  squamous-celled  carcinoma  is  diagnosed,  the  growth  should  be 
excised  with  a  large  area  of  the  surrounding  skin,  and  at  the  same 
time  the  superficial  inguinal  glands  should  be  removed  from  both 
groins.  If  the  growth  has  become  adherent  to  one  of  the  testes,  the 
gland  should  be  removed  without  hesitation. 

Melanotic  Sarcoma 
Although  the  scrotum  is,  as  a  rule,  deeply  pigmented,  melanotic 
sarcoma  is  not  common.     If  it  occur  it  has  the  same  characters  and 


IMPOTENCE  981 

clinical  course  .1-  these  neoplasms  elsewhere,  and  demands  t he  same 
itment.    The  inguinal  glands  should  always  be  removed. 

[NNOCENT    GROWTHS 

All  varieties  of  innocent  aew  growths  are  uncommon  in  the  scrotum, 
and  they  differ   in   no  respect   from  Bunilar  growths  in  other  parte  of  the 
body.     The  least  uncommon  are  angioma,  fibroma,  lipoma,  and  fibre-cellular 
tumours.     Lipoma   may  attain  a  1 1  u >_r< •  Bize,  the  growth  in  one  reported 
weighing  11  lb. 

Seba<  eous  <  Iysts 

Sebaceous  cysts  of  any  Bize  are  uo(  common  in  the  scrotum.  They  have 
the  usual  features  of  sebaceous  cysts  elsewhere,  and  it  aecessarj  should  be 
rem<  ived. 

LYMPH  SCROTUM— ELEPHANTIASIS  OF  THE  SCROTUM 
Although  thickening  of  the  skin  and  subcutaneous  tissues  of  the  .-<  rotum 
from  lymphatic  obstruction  may  occur  from  several  causes,  such  as  syphilitic 
ulceration  in  the  groin,  sloughing  of  the  inguinal  glands,  or  their  complete 
removal  for  malignant  disease,  lymph  scrotum  and  elephantiasis  are  essen- 
tially a  manifestation  of  filariasis,  a  tropical  disease  due  to  invasion  of  the 
bodv  bv  the  nematode  FUaria  Bancrofti.  Lymph  scrotum  is  the  forerunner 
of  elephantiasis,  and  it  is  hardly  necessary  to  separate  the  two  conditions. 
The  subject  has  been  sufficiently  considered  elsewhere  (Vol.  L,  p.  '-'I  1  , 

IMPOTENCE 
Impotence  is  a  condition  in  which  the  ability  to  have  normal  sexual 
intercourse  is  lost,  or  very  much  lessened.  This  condition  must  be 
carefully  distinguished  from  sterility,  in  which  there  is  a  defect  in  the 
Bemen  rendering  it  incapable  of  fertilizing  the  ovum.  A  patient  who 
is  impotent  is  usually  sterile,  but  not  necessarily  so.  for  the  semen  may 
be  ejaculated  and  be  artificially  conveyed  to  the  vagina.  For  example, 
in  cases  in  which  the  semen  is  ejaculated  with  only  partial  erection  of 
the  penis  the  patient  may  be  impotent,  but  should  the  semen  gain 
entrance  to  the  vagina  conception  may  follow.  Impotence  may  be 
considered  under  the  following  heads  : — 

1.  Impotence  due  to  physical  defects  in  the  genital  organs. 

2.  Impotence  due  to  abnormal  psychical  conditions. 

3.  Xervous  impotence. 
-4.  Paralytic  impotence. 

1.  Physical  defects. — Under  this  heading  are  grouped 
of  impotence  due  to  congenital  abnormalities  such  as  hypospadias, 
epispadias,  rudimentary  penis,  to  mutilation,  elephantiasis  of  the  penis, 
large  hernias  and  hydroceles,  and  to  induration  of  the  penis  and  loss 
of  power  of  erection  following  fracture  of  the  penis,  gonorrheal  and 
goutv  inflammation  of  the  cavernous  tissue,  periurethral  abscesses,  etc. 
Hvpospadias  and  epispadias  only  cause  impotence  if  present  in  an 
advanced  degree,  many  patients  with  these  defects  having  the  power 


IMPOTENCE 

to  copulate,  although  the  semen  does  not  reach  the  vagina.  Impotence 
due  to  large  hernias,  hydroceles,  and  elephantiasis  can  usually  he  cured 
by  suitable  operations.  In  cases  of  obliteration  of  part  of  the  cavernous 
tissue  of  the  penis  due  to  previous  inflammation  01  to  trauma,  the 
prognosis  is  not  good,  but  treatment  by  iodides,  fibrolysin,  or  local 
application  of  mercurials  may  be  beneficial.  Excision  of  the  induration 
is  sometimes  successful. 

2.  Psychical  impotence — Impotence  of  this  variety  may  be 
relative  or  absolute,  and  is  most  commonly  found  in  men  who  have 
overtaxed  their  sexual  power  either  by  excessive  masturbation  or  by 
sexual  intercourse.  The  condition  is  full  of  interesting  and  curious 
anomalies.  The  patient,  for  instance,  may  be  fully  capable  and  active 
in  Ins  intercourse  with  prostitutes,  but  cannot  have  intercourse  with 
his  wife.  In  other  cases,  something — often  of  a  bizarre  nature— is 
necessary  as  an  extra  stimulus  before  erection  or  ejaculation  can 
occur.  The  condition  may  be  congenital,  the  natural  impulse  to  sexual 
intercourse  being  altogether  wanting,  but  it  is  usually  acquired,  and, 
with  the  exception  of  excessive  venery,  mental  overwork  seems  to  be 
the  most  common  cause. 

The  fear  of  failure  in  intercourse  may  be  the  cause  of  psychical 
impotence,  the  patient,  who  may  have  been  a  masturbator  or  may 
have  indulged  freely  in  venery,  being  persuaded  that  he  has  lost,  or 
fearing  he  may  have  lost,  the  power  of  copulation.  This  condition 
not  seldom  arises  when  marriage  is  contemplated,  and  the  fear  may 
be  sufficient  to  inhibit  the  sexual  act.  Allied  to  psychical  impotence, 
and  sometimes  associated  -with  it,  is  perverse  sexual  feeling.  The 
usual  stimulus  to  sexual  excitement  fails  in  these  patients,  but  their 
sexual  nature  is  excited  by  circumstances  that  have  no  such  effect 
on  the  normal  man.  In  these  cases  sexual  intercourse  may  fail  because 
of  the  absence  of  the  abnormal  exciting  circumstance,  although  the 
sexual  feelings  may  be  strong.  These  cases  gradually  merge  with 
those  in  which  sexual  impulses  towards  persons  of  the  same  sex  or 
towards  animals  are  present. 

Sexual  passion  for  one;s  own  sex,  or  paederasty,  may  be  congenital 
or  acquired.  The  acquired  form  is  usually  seen  in  elderly  people  who 
have  indulged  in  sexual  excesses  and  whose  senses  have  been  dulled  to 
normal  stimuli.  Or  again,  in  large  communities  of  men,  such  as  in 
monasteries,  and  in  training-ships  and  boarding-schools,  the  absence 
of  individuals  of  the  opposite  sex,  combined  with  the  natural  sexual 
cravings,  may  lead  to  acts  of  perverted  sexual  intercourse,  and  these, 
frequently  indulged  in,  may  deprive  the  patient  of  the  power  [of 
intercourse  with  members  of  the  opposite  sex,  owing  to  the  absence 
of  the  customary  stimuli. 

The  treatment  of  psychical  impotence  consists  in  moral  control, 


IMPOTENCE  9S3 

abstinence  foi  a  time  from  attempts  at  Beznal  intercourse,  physical 
exercise,  mental  occupation,  and  common  sense. 

3.  Nervous  impotence.  This  condition  is  one  oi  irritable 
weakness  oi  the  sexual  centres  in  the  <  <>rd  or  brain,  resulting  in  impor- 
ted erection  of  the  penis,  with  premature  ejaculation.  The  patients 
are  usually  neurasthenics  who  may  uol  have  indulged  in  sexual  inter- 
course, but  in  other  cases  they  have  been  habitual  masturbators.  The 
penis  becomes  ereel  or  partially  erect  under  the  normal  stimuli,  bu1 
the  erection  passes  ofi  before  intercourse  can  lie  indulged  in,  or  the 
semen  1-  ejaculated  at  the  momenl  of  intromission  into  the  vagina,  or 

in  before.  These  patients  often  fear  marriage  because  they  feel 
they  are  not  capable  of  sexual  intercourse,  and  psychical  impotence 
may  be  added  to  the  nervous  impotence. 

The  treatment  of  nervous  impotence  is  similar  to  that  of 
psychical  impotence. 

•i.  Paralytic  impotence. — This  form  of  impotence  differs 
from  the  three  previous  forms  in  that  in  them  erection  of  the  penis 
occurs  with  the  ejaculation  of  semen,  but  the  erection  is  not  properly 
used,  while  in  tliis  variety  of  impotence  erection  does  not  occur.  It 
may  be  due  to  excessive  indulgence,  especially  in  the  form  of  mastur- 
bation, but  is  more  commonly  due  to  organic  disease.  It  may  occur 
in  certain  chronic  diseases  such  as  diabetes,  anaemia,  phthisis,  morphin- 
ism, in  certain  diseases  of  the  brain  and  cord  such  as  tabes  dorsalis, 
general  paralysis  of  the  insane,  or  injury  or  disease  of  various  cerebral 
centres.  The  condition  may  also  follow  atrophy  of  the  testis  from 
disease  or  loss  by  injury  or  operation,  but  not  necessarily. 

Certain  drugs  such  as  alcohol,  iodine,  salicylic  acid,  and  potassium 
nitrate  can  also  cause  diminution  of  the  sexual  powers,  but  the  loss  is 
usually  recovered  directly  the  use  of  the  drug  is  stopped. 

Treatment  in  many  cases  of  paralytic  impotence  is  useless, 
and  in  others,  such  as  those  due  to  the  use  of  drugs,  is  obvious. 
In  all  cases  of  impotence,  self-control,  with  a  clean,  healthy  mode  of 
life  and  thought,  is  of  the  utmost  importance. 

BIBLIOGRAPHY 
Casper.   Urinary  Surgery.    1911. 
Cooper.  Astley..  Diseases  of  the  Testis.     1830. 
Curling,   Diseases  of  the  Tint's,  4th  ed.     1S7S. 
Eccles,  W.  McAdara,   Imperfectly  Descended  Testis.     1903 
Fenwick.  E.  H..  Clinical  Cystoscopy.    1904. 
Fuller.  Diseases  of  tht   Qenito  •  Urinary  System.     1900. 
Hutchinson.  Sir  Jonathan,  8yphUis.     1909. 

Jacobson.  W.  H.  A.,  Diseases  of  the  Male  Organs  oi  Generation,    1893. 
Mansell-Moullin,  C.  W..  Enlargement  of  the  Prostate.    1894. 
Manson.  Sir  Patrick,   Tropical  Diseases.     1907. 
Monod  tt  Teril'on,   Trade  des  Maladies  du    Testicvle.     1889. 


THE    FEMALE    GENITAL    TRACT 

By  VICTOR  BONNEY,  M.S.,  M.D.,  B.Sc.Lond., 
F.K.C.S.Eng. 

History. — Xote  should  be  taken  of  the  patient's  age.  her  symptoms 
and  their  duration,  the  dates  of  any  pregnancies,  the  frequency  and 
duration  of  the  menses  and  the  date  of  the  last  om  . 

If  pain  be  present,  its  position  and  its  relation  to  posture  and  to 
the  menstrual  period  should  be  ascertained. 

Examination  in  the  consulting-room  is  best  conducted  with  the 
patient  lying  half  on  her  side  and  half  on  her  back,  but  with  the 
shoulders  more  horizontal  than  the  hips,  so  that  the  trunk  is  some- 
what twisted  ^t  the  waist.  This  position  allows  the  examiner  to 
apply  his  weight  through  his  left  hand  on  the  patient's  abdomen, 
and  materially  facilitates  bimanual  examination.  Vaginal  examina- 
tion should  be  made  with  one  finger,  as  two  may  cause  pain,  and  is 
assisted  by  turning  the  patient  during  its  performance,  first  into  the 
semi-prone  and  then  into  the  semi-supine  position.  By  this  manoeuvre 
the  quadrants  of  the  pelvis  are  successively  rendered  more  accessible. 

In  bimanual  examination,  palpation  must  be  chiefly  conducted  by 
the  hand  on  the  abdomen,  the  finger  in  the  vagina  being  held  stationary 
on  the  cervix  or  vaginal  vault.  ;'  Gravity  "  displacements  like  prolapse 
or  retroversion  should  be  investigated  with  the  patient  standing  erect. 

Rectal  examination  is  often  useful,  especially  in  virgins.  The  tyro 
must  be  careful  not  to  mistake  the  projection  of  the  vaginal  cervix 
for  a  tumour  in  front  of  the  rectum. 

The  speculum. — An  expert  can  distinguish  almost  all  diseases 
of  the  vagina  and  vaginal  cervix  by  touch  alone,  and  therefore  can 
frequently  spare  his  patient  the  discomfort  of  examination  by  speculum, 
Fergusson's  speculum  is  easy  to  introduce,  but  shuts  up  the  lips  of  a 
lacerated  cervix,  and  fails  to  demonstrate  the  condition  of  the  cervical 
canal.  Sims's  speculum  in  a  narrow  vagina  may  fail  to  show  the 
cervix  well.  The  hinged  bivalve  speculum  is  better  for  consulting- 
room  use. 

The  uterine  sound. — This  instrument  is  much  less  employed 
than  formerly.      The   direction   of  the  uterus   can   be   estimated    by 


THE    VULVA  985 

bimanual  examination,  while  the  measurement  of  the  length  «>f  the 
cavity  is  of  doubtful  utility,  for  great  enlargement  1-  obvious  by  other 
means,  and  small  alterations  in  length  (an  inch  <»r  less),  as  revealed 
by  tin-  Bound  passed  without  anaesthesia,  arc  often  due  to  the  point  of 
the  instrument  deviating  into  .1  cornu. 

The  habitual  use  of  the  sound  in  the  consulting-room  will  result 
sooner  or  later  in  its  passage  into  a  pregnanl  uterus  by  mistake.  Cases 
undiagnosable  by  bimanual  examination  Bhould  be  examined  under 
an  anaesthetic  and  the  sound  passed  then. 

Examination  under  anaesthesia  is  advisable  when  serious 
Bymptoms  are  present  and  diagnosis  by  ordinary  examination  is 
obscure.     The  lithotomy  position  is  the  right   one  fur  this  purpose. 

THE   VULVA 

DEFORMITIES   AND    DISPLACEMENTS 

PSEUDO-HERMAPHRODISM 

Malformations  of  the  vulva  are  rare.  The  commonest  is  that  .seen  in  a 
pseudo-hermaphrodite  hypospadia*  male.  This  subject  is  discussed  in  the 
preceding  article  (p.  970 

PROLAPSE  OF  THE  URETHRA 
Prolapse  of  the  urethral  mucosa  occurs  in  elderly  women.  The 
protrusion  is  purple-red  in  colour,  with  a  central  aperture,  and  may 
be  much  inflamed  or  ulcerated.  The  patient  complains  of  a  very 
tender  swelling  and  of  difficulty  and  pain  in  micturition.  The 
central  orifice  in  the  swelling  differentiates  it  from  new  growths  in 
this  situation.  The  redundant  mucosa  should  be  amputated  circu- 
larly and  the  cut  edge  of  the  urethra  united  to  the  surface  by  fine 
silk  sutures.  Care  must  be  taken  not  to  remove  the  mucous  membrane 
of  the  vestibule,  but  to  limit  the  excision  to  that  belonging  to  the 
canal,  otherwise  stenosis  may  occur. 

URETHROCELE 

A  urethrocele  is  a  protrusion  consisting  of  the  lower  inch  of  the 
anterior  vaginal  wall,  and  containing  a  pouched  portion  of  the  urethra. 
The  condition  is  met  with  in  multipara  in  whom  the  perineum  is 
deficient.     The  patient   is  conscious  of  a  lump  which  protrudes  on 

:ding  or  straining.  After  the  expulsive  act  of  micturition,  dribbling 
occurs  as  the  distended  pouch  empties  itsell 

Treatment  consists  in  excision  of  the  redundant  portion  ol   th 
vaginal   wall,    together   with   the   prolonged    portion   of   the   urethra, 
followed  by  closure  of  the  openings  in  the  walls  of  the  canals  by  s<  parate 
rows  of  sutures.    Perineoplasty  is  then  performed  to  prevent  r  icurrence. 


THE   VULVA 

INFLAMMATION 
STREPTOCOCCAL   AND    PNEUMOCOCCAL    VULVITIS 

Infection  'with  the  streptococcus  or  pneumococcus  may  be  primary 
after  wounds,  surgical  operations,  and  labour  ;  occasionally  it  is  a 
secondary  infection  added  to  previous  lesions,  notably  soft  chancres 
and  syphilis. 

When  primary,  the  type  is  usually  erysipelatous  with  much  brawny 
swelling,  but  it  may  be  gangrenous,  especially  in  debilitated  children 
(noma  vulva).  In  secondarily  infected  venereal  sores  the  inflammation 
may  be  most  destructive,  and  terminate  in  wholesale  sloughing  of  the 
external  genitals  (phagedenic  vulvitis). 

Treatment. — Antiseptic  fomentations  should  be  applied,  stitches 
removed  from  operation  wounds,  and  constitutional  symptoms  met  by 
the  injection  of  an  appropriate  antitoxic  serum,  or  vaccine.  In  the 
rare  form  of  phagedsenic  inflammation  the  necrotic  tissue  should  be 
scraped  away  with  a  sharp  spoon  and  the  parts  well  swabbed  over 
with  pure  carbolic  acid. 

STAPHYLOCOCCAL    VULVITIS    (SDIPLE    VULVITIS) 

Simple  vulvitis  may  occur  after  any  wound  of  the  vulva,  or  may 
be  due  to  the  irritation  of  scratching  (pruritus  vulvae),  diabetic  urine, 
ichorous  vaginal  discharge,  rough  diapers,  or  masturbation.  The 
surface  is  red.  sore,  and  excoriated.  In  many  cases  it  is  associated 
with  vaginitis,  as  in  the  vulvo-vaginitis  of  little  children.  Antiseptic 
fomentations  and  lotions  are  usually  sufficient,  combined  with  the 
removal  of  any  discoverable  cause.  In  young  children  vulvitis 
cannot  be  cured  until  the  vaginitis  is  well.  These  cases  are  of  medico- 
legal importance,  and  the  pus  should  be  carefully  examined  for  evidence 
of  venereal  infection.     (See  Vaginitis,  p.  996.) 

GONOCOCCAL  VULVITIS 
Acute  gonorrhoea  in  the  female  consists  of  a  coincident  inflammation  of 
the  vaginal  cervix,  vagina  and  vulva  (cervico-vagino-vtdvitis).  The  subject 
is  discussed  in  Vol.  I.,  pp.  832-34.  Owing  to  the  resistant  nature  of  the 
vulval  tissues  the  inflammation  may  have  entirely  subsided  in  them  while 
still  active  in  the  vagina  and  cervix. 

OTHER    VENEREAL    AFFECTIONS    OF    THE    VULVA 

The  typical  hard  chancre  is  rarely  met  with  on  the  vulva.  Instead, 
the  sores  are  multiple,  ulcerative,  or  sometimes  warty.  "With  these 
is  associated  much  swelling  of  the  labia  minora  due  to  lymphangitis, 
which  often  hinders  a  satisfactory  view  of  the  parts.  Inspection  alone 
will  generally  fail  to  determine  whether  the  lesion  is  syphilitic  or  merely 
chancroidal,  especially  as  the  two  conditions  may  coincide.  In  either 
case  the  venereal  element  mav  be  much  accentuated  by  secondarv 


VENEREAL    AFFECTIONS  9»7 

infection  with  pyogenetic  01  necrogenetic  organisms,  Leading  to 

ruction  of  the  pari 

In  the  secondary  period  of  syphilis  various  manifestations  may 
a  on  the  vulva,  usually  taking  the  form  ol  superficial  ulcerations 
with  elevated  warty  edges.  The  initial  swelling  ol  the  labia  minora 
due  to  lymphangitis  may  persist,  and  result  in  an  elephantoid  hyper- 
trophy. 

Tertiary  lesions  are  rare  on  the  vulva,  but  when  occurring  take  the 
form  of  gummatous  masses  which  by  their  subsequent  changes  may 
-ion  much  deformity. 

Venereal  warts,  though  commonly  known  as  "  gonorrhceal,"  are  not 
due  to  the  gonococcus.  They  may  occur  without  gonorrhoea,  and 
occasionally  in  situations  other  than  the  vulva  (e.g.  the  umbilicus). 
Microscopically  they  are  pure  papillomas.  They  are  multiple,  grow 
rapidly,  and  may  attain  an  enormous  size,  the  surface  resembling  that 
of  a  cauliflower.    They  emit  a  foul  odour  and  a  serous  discharge. 

Treatment. — Mercury  should  not.  as  a  rule,  be  administered  until 
the  diagnosis  of  syphilis  is  certain.  Meanwhile  the  local  condition 
should  be  treated  by  frequent  irrigation  with  biniodide  of  mercury 
solution  (1-1.000),  and  by  the  application  of  boric  ointment  on  a 
piece  of  lint  inserted  between  the  labia.  After  the  lymphangitis  has 
subsided  the  ulcers  are  best  treated  with  a  dusting  powder  such  as 
aristol.     If  the  inguinal  glands  suppurate  they  must  be  opened. 

Secondary  lesions  may  be  similarly  treated,  the  patient  having  been 
put  on  a  mercurial  course  or  treated  by  salvarsan.  Tertiary  lesions 
require  iodide  of  potassium  internally,  combined  with  mercury.  Re- 
ference has  already  been  made  to  the  local  treatment  of  phagedena. 

Venereal  warts  should  be  snipped  away  with  scissors.  Oozing  may 
be  considerable,  but  can  be  checked  by  sutures  or  by  the  light  appli- 
cation of  a  dull-red  cautery.  Elephantoid  hypertrophy  of  the  labia 
minora  is  treated  by  excision. 

TUBERCULOUS    VULVITIS 

This  is  very  rare,  and  is  almost  invariably  associated  with  tuberculosis 

elsewhere.  The  ulcers  are  very  painful,  often  foul,  and  may  even  be  mis- 
taken for  malignant  disease  on  account  of  the  granulomatous  thickening  of 
the  tissue.-.  The  diagnosis  can  only  be  made  by  examination  of  an  excised 
portion  of  the  tissue.  The  ulcers  should  be  scraped  with  a  sharp  spoon  until 
healthy  tissue  is  reached,  and  carbolic  acid  then  applied.  In  some  cases 
excision  of  the  diseased  area  is  feasible.     Vaccine  treatment  is  of  value. 

HERPES    OF    THE    VULVA    (APHTHOUS    VULVITIS) 

Occasionally  shallow,  whitish  excoriations  are  found  on  the  vulva, 
producing  considerable  irritation.  They  are  distinguished  from  vene- 
real disease  by  the  absence  of  swelling,  of  labial  lymphangitis,  and  of 


988 


THK    VULVA 


glandular  enlargement.  Their  cause  is  unknown  :  clinically  they  re- 
semble aphthous  ulcers  of  the  mouth.  Bathing  with  a  simple  antiseptic 
lotion  suffices. 

LEUCOPLAKIC  VULVITIS 
This  very  interesting  affection  lias  only  lately  been  distinguished 
from  kraurosis  of  the  vulva.1  Its  cause  is  unknown.  It  begins  as 
a  diffuse  redness  with  intense  itching,  later  on  the  surface  becomes 
white  from  epithelial  hypertrophy,  and  the  thickened  tissues  retract, 
so  that  the  labia  minora  and  hood  of  the  clitoris  almost  disappear. 
The  subepithelial  changes  consist  of  diffuse  lymphocytosis,  the  appear- 
ance of  plasma  cells  and 


%N^ 


Leucoplakic  vulvitis. 


The  epithelium  is  thickened  and  the  tissue  immediately 
underlying  it  is  devoid  of  elastic  fibres. 


complete  disappearance 
of  elastic  fibres.  (Fig. 
."379. )  Painful  fissures 
may  develop,  and  in 
many  cases  squamous* 
celled  carcinoma  super- 
v  e  n  e  s.  In  other  s, 
extensive  subepithelial 
fibrosis  results,  and  the 
parts  present  a  white 
and  "  ironed-out :'  ap- 
pearance. This  is  a 
quiescent  stage,  in 
which  the  characteristic 
intense  pruritus  disap- 
pears, while  the  lia- 
bility to  carcinoma 
diminishes. 

The  disease   is  most 


intractable,      the       pru- 
ritus  often   defying   all    treatment.       Pathologically    it    is    of    - 
interest,  as,  next  to  X-ray   burns,  it  affords  the  best  example   of  a 
precarcinomatous  state. 

The  parts  affected  are  the  labia  minora,  the  hood  of  the  clitoris, 
the  inner  surface  of  the  labia  majora,  and  sometimes  the  skin  a-  i 
back  as  the  anus.     The  vestibule  and  vaginal  introit  escape. 

Treatment. — Of  the  many  applications  used  for  relief  of  the 
pruritus,  those  most  likely  to  succeed  are  zymocide  lotion  and  resinol 
ointment,  but  weak  alkaline  carbolic  lotion  (phennate  of  soda)  is  alg  i 
useful.  Iodide  of  mercury  ointment  may  also  be  tried.  These  failing, 
recourse  should  be  had  to  the  X-rays  and  to  zinc-mercury  ionization. 
In  the  last  resort  the  affected  parts  must  be  excised. 

i  <$'<<-  a  paper  by  the  author  and  Comyne  Berkeley,  I'roc.  Boy.  Soc.  Mid. 


URETHRAL   CARUNCLE  989 

KRAUROSIS    VI  l.v.K 

This  condition  was  firs!  described  by  Briesky.  In  the  early  »l 
tiple  red  patches  are  seen  around  the  vaginal  introit  and  on  the 
vestibule.  The  urethra  is  usually  carunculous.  Microscopically,  the 
red  patches  consist  of  massive  aggregations  of  plasma  cells  with  many 
dilated  capillaries.  The  epithelium  over  them  is  thinned.  Later, 
shrinkage  occurs  around  the  introit.  while,  the  whole  vulva  becomes 
atrophic  and  its  inner  surface  smooth  and  shiny.  (ire, it  aoreness  and 
dyspareunia  are  early  symptoms;  later  the  dyspareunia  may  also  be 
experienced  by  the  male.  The  disease  is  very  intractable.  In  the 
earlier  phases  sedative  ointments  may  he  tried.  Dyspareunia  or  other 
distress  is  best  treated  by  dissecting  out  the  diseased  area  and  at  tip- 
same  time  performing  a  plastic  operation  to  enlarge  the  vaginal  orifice 
(p.  993).    Recurrence  is  common. 

QRETHRAL   CARUNCLE 

A  urethral  caruncle  appears  as  a  bright  scarlet  "cockscomb-like" 
protuberance  from  the  posterior  edge  of  the  urethral  orifice.  Occasion- 
ally, however  the  whole  orifice  may  be  carunculous  without  localized 
protrusion.  The  formation  is  entirely  inflammatory,  and  microscopic- 
ally presents  the  features  of  a  massive  plasma-cell  aggregation  (plas- 
morna)  intermixed  with  lymphocytes.  Its  colour  is  due  to  numbers 
of  dilated  thin-walled  capillaries.  Embedded  in  its  deeper  parts  may 
be  found  elements  of  the  urethral  glands.  The  condition  usually 
occurs  in  elderly  women,  and  frequently  in  association  with  kraurosis, 
to  which  disease  it  bears  a  definite  histological  relation  ;  but  it  is 
occasionally  seen  in  the  young.  The  symptoms  are  those  of  great  sore- 
dysuria,  dyspareunia  and  occasional  bleeding,  but  sometimes  a 
caruncle  may  inexplicably  cause  no  symptoms.  The  caruncle  should 
he  snipped  off  with  scissors  and  its  base  well  burned  with  the  cautery. 
Recurrence  is  extremely  likely  ;  if  this  happens,  the  lower  end  of  the 
urethra  should  be  dissected  free  and  removed,  and  the  cut  edge  of 
the  upper  portion  sutured  to  the  vestibular  mucosa. 

ABSCESS  OF  THE  VULVA 
The  labia  majora  are  occasionally  the  seat  of  boils  or  carbuncles. 
Suppuration  may  also  occur  in  one  of  the  numerous  glands  of  the 
lesser  lips.  The  commonest  form  of  vulval  abscess  is  that  of  Bartholin's 
gland  at  the  vaginal  introit.  Primary  infection  of  this  gland  is  common 
in  gonorrhoea,  but  may  also  be  due  to  non-venereal  pyogenetic  cocci. 
Frequently  a  retention  cyst  of  the  gland  has  preceded  the  infection. 
Redness,  swelling  and  pain  appear  in  the  neighbourhood  of  the  gland. 
and  pus  eventually  points  on  the  inner  surface  of  the  swelling.  Where 
the  condition  is  complicated  by  previous  cyst  formation,  a  persistent 


99o  THE   VULVA 

sinus  leading  to  the  cyst  wall  is  commonly  formed.  In  any  ease  there 
is  a  great  tendency  to  repeated  recurrence.  Boric-acid  fomentations 
should  be  applied,  and  the  abscess  opened  and  drained.  If  a  cyst  is 
present  an  attempt  should  be  made  to  remove  the  wall,  otherwise  a 
sinus  will  remain. 

VULVAL   CYSTS 

BARTHOL1NIAN  CYST 
A  cyst  is  frequently  formed  in  the  duct  of  Bartholin's  gland.  The 
cause  is  unknown.  It  presents  as  an  oval  swelling  bulging  inwardly 
into  the  introit  and  outwardly  under  the  lower  end  of  the  labia.  It 
i.s  always  unilocular,  and  contains  a  clear  mucus,  unless  inflamed, 
when  the  contents  may  be  brownish  and  thick  or  frank  muco-pus. 
Complaint  is  made  of  discomfort  and  the  presence  of  a  swelling  ;  if 
inflammation  occurs,  pain  is  severe.  The  cyst  should  be  excised  whole, 
through  an  incision  over  its  inner  surface.  Where  suppuration  has 
occurred,  this  dissection  may  be  impossible.  As  much  as  possible  of 
the  cyst  wall  should  then  be  removed  and  the  cavity  packed  lightly 
with  gauze  and  allowed  to  granulate. 

LABIAL    CYSTS 

In  the  labia  majora  sebaceous  cysts  are  not  uncommon.  A  cyst  of 
the  vestigial  "  canal  of  Nuck"  {hydrocele  of  the  canal  of  Nuck)  is  some- 
times seen  as  an  elongated  swelling  extending  downwards  from  the 
external  inguinal  ring,  and  may  be  mistaken  for  an  inguinal  hernia 
and  especially  for  a  hydrocele  of  a  hernial  sac.  In  the  labia  minora 
sebaceous  cysts  are  also  common.  Occasionally  thin-walled  peduncu- 
lated cysts  are  met  with  containing  a  clear  fluid.  They  probably  repre- 
sent distended  odoriferous  (Tyson's)  glands.  The  cysts,  of  whatever 
nature,  should  be  excised.  A  hydrocele  of  the  canal  of  Nuck  may 
communicate  with  the  peritoneal  cavity,  and  may  be  difficult  to  dis- 
tinguish from  a  hernial  sac  ;  therefore  its  interior  and  contents  should 
always  be  examined  before  excision. 

URETHRAL    CYSTS 

Skene's  tubules,  or  the  numerous  crypts  opening  through  the 
posterior  urethral  wall,  may  occasionally  be  the  origin  of  cysts.  They 
present  as  a  rounded  fluctuating  swelling  that  bulges  into  the  vagina. 
They  resemble  a  urethrocele,  but  a  sound  inverted  into  the  urethra 
does  not  pass  into  the  swelling.  They  may  contain  pus.  If  they 
Lfive  rise  to  trouble  they  should  be  dissected  out. 

OTHER    INNOCENT    GROWTHS 

Venereal  warts  have  already  lieen  considered  (p.  987).  Solitary  non- 
venereal  papillomas  and  soft  fibromas,  often  pedunculated,  are  occasionally 


MALIGN  W T    DISE  \SI. 

Lipomas  may  oocui  in  the  labia  m.ij< >r.i  or  mons  veneris.     Very  rarely 
solid  adenomas  springing  from  the  a  is  or  odoriferous  glands 

recorded.     The  treatment  in  all  cases  consists  in  excision, 

VULVAL   NEW   GROWTHS 

MALIGNANT    GROWTHS 

Squamous-celled  carcinoma  of  the  vulva  is  not    uncommon, 

ilmost  constanl  association  with  a  pre-existing  leucoplakic  vulvitis 
(p.  988)  has  been  noted. 

There  are  three  common  clinical  forms  ;1)  the  warty.  (2)  the 
ulcerative,  auil  (3)  a  superficial  erosive,  which  at  first  sight  does  not 
perhaps       _  malignancy. 

The  disease  occurs  in  old  women,  and  may  at  first  run  a  slow  couise. 
Eventually  the  inguinal  glands  become  affected,  rapidly  enlarge,  and 
soften  and  break  down. 

There  is  a  fourth,  and  rarer,  type,  viz.  that  analogous  to  "  sweeps' 

<er"  of  the  scrotum,  which  usually  begins  on  the  labia  majora. 
Lastly,  examples  of  adeno-carcinoma  of  tilandular  origin  are  on  record. 

Sarcoma  of  the  vulva  is  known,  and  is  sometimes  of  the  melanotic 
variety. 

Treatment. — The  whole  vulva  should  be  excised,  together  with 
the  inguinal  glands  on  both  sides. 

In  excising  the  vulva,  two  incision-  .  re  required,  an  outer,  which 

■  prises  the  whole  area,  and  an  inner,  to  exclude  the  orifices  of  the 
vagina  and  urethra.  At  the  conclusion  of  the  operation  these  latter 
are  stitched  to  the  skin  ed<_fes  of  the  wound. 

THE     VAGINA 
DEFORMITLES  AND  DLSPLACEMENTS 

In  early  fcetal  life  the  Mullerian  ducts  end  blindly  in  the  Mullerian 
tubercle,  an  eminence  lying  in  relation  with  the  bladder  and  Wolffian 
<lucts  in  front,  the  lower  bowel  behind,  and  the  urogenital  sinus 
below. 

The  Mullerian  ducts  fuse  below  to  form  the  uterus  and  vagina,  and 
the  tissue  between  the  Mullerian  tubercle  and  the  wall  of  the  urogenital 
sinus  is  gradually  hollowed  out  until  the  vagina  opens  on  the  surface. 

IMPERFORATE    VAGINA    ("IMPERFORATE  HYMEN    i 
Etiology. — This   condition  i-   caused   by    failure  of    the    fused 
Mullerian  tube   to  perforate  the   wall   of  the  urogenital  sinus.     The 
septum  represents  part  of  the  wall  of  the  urogenital  sinus.     The  hymen 

itself  is  never  imperforate,  and  in  tli cases  it  may  be  seen  stretched 

out  on  the  septum,  but  not  forming  part  of  it. 


c92  THK   VAGINA 

Clinical  features. — The  girl  does  not  menstruate,  and  after 
a  time  complains  of  periodic  attacks  of  pain  lasting  for  some  days. 
These  increase  in  severity  and  duration,  until  in  advanced  cases  the 
patient  is  never  free  from  pain.  The  abdomen  becomes  swollen  and 
tender,  and  micturition  is  difficult.  These  symptoms  are  due  to  the 
progressive  distension  with  retained  blood,  first  of  the  vagina  (hcemato- 
colpos),  and  later  of  the  cervix  (hcBmatotrachdos)  and  Fallopian  tubes 
(hcematosabpinx).     The  uterus  itself  is  very  rarely  distended. 

The  distension  of  the  tubes  is  soon  followed  by  more  or  less  pelvic 
peritonitis  due  to  the  escape  of  the  blocd  through  the  abdominal  ostia 
(hematocele). 

On  abdominal  examination  a  definite  swelling  is  felt.  If  there  is 
much  tenderness,  distension  of  the  tubes  may  be  inferred.  Vaginal 
examination  reveals  the  stretched  septum,  bulging,  very  tender,  and 
of  bluish  colour  owing  to  the  blood  behind  it. 

Treatment. — The  retained  inspissated  blood  must  be  evacuated 
by  free  crucial  incision  of  the  septum  with  most  rigid  aseptic  precau- 
tions ;  if  the  cervix  and  tubes  are  distended  there  is  a  peculiar  liability 
to  ascending  infection  which,  leading  to  acute  salpingitis,  may  cause 
death  from  general  peritonitis. 

Where  hseniatocolpos  alone  exists,  i.e.  where  the  unenlarged  uterus 
can  be  felt  on  the  top  of  the  distended  vagina,  evacuation  may  be 
accelerated  by  flushing  out  the  collapsed  vaginal  cavity  with  hot  sterile 
water.  If,  however,  there  is  any  suspicion  that  the  uterus  itself  is 
distended,  it  is  better  not  to  douche,  lest  the  fluid  be  driven  up  the 
distended  tubes.  In  these  cases  the  vagina  should  be  simply  allowed 
to  drain,  the  patient  being  kept  in  the  sitting  posture. 

ABSENCE    OF    THE    VAGINA,    COMPLETE   OR    PARTIAL 

The  whole  vagina,  or  its  upper,  middle,  or  lower  third,  may  be 
absent.  The  defect  is  due  to  failure  in  the  complete  formation  of 
the  Miillerian  ducts. 

Clinical  features. — Patients  suffering  from  this  deformity 
seek  advice  on  one  of  three  grounds — (1)  amenorrhoea,  (2)  symptoms 
of  retained  menstrual  blood,  or  (3)  marital  difficulty. 

Treatment. — Since  these  graver  vaginal  defects  are  commonly 
associated  with  uterine  maldevelopment,  symptoms  due  to  retained 
menstrual  blood  are  not  usual.  In  such  circumstances  plastic  opera- 
tion attempts  are  of  doubtful  value,  for,  apart  from  the  difficulty  of 
fashioning  a  serviceable  canal,  these  patients  are  in  nature  sexually 
deficient  and  unsuited  for  married  fife.  Where,  however,  a  functional 
uterus  is  indicated  by  the  presence  of  a  cystic  tumour  and  recurring 
monthly  pain,  completion  of  continuity  of  the  genital  canal  is  worth 
attempting,   if  the  defect  is  not  more  than  2  in.  long. 


VAGINAL   DEFECTS  993 

By  careful  dissection   between   the  bladder  and   the  rectum   the 

distended  cervix  or  upper  pari  of  the  vagina  i  the  case  may  be,  is 
reached.  The  retained  blood  having  tieen  evacuatnl.  the  wall  of  the 
cavity  is  Ereed,  pulled  down,  ami  sutured  to  the  lower  part  of  the  canal 
or  to  the  surface  skin.  Systematic  dilatation  tnusl  be  employed  for 
many  months  afterwards. 

Where  the  length  of  vagina  to  be  restored  exceeds  2  in.  hysterect<>mv 
should  be  performed.  Baldwin  has  successfully  constructed  a  vagina 
on  four  occasions  by  transplanting  a  portion  of  the  ileum  between 
the  bladder  and  the  rectum. 

DOUBLE    VAGINA 

This  deformity  is  due  to  want  of  fusion  of  the  vaginal  segments 
and  of  the  Miillerian  ducts.  It  is  usually,  but  not  always,  associated 
with  a  double  uterus  ;  when  it  is  not,  the  longitudinal  septum  ends 
just  below  the  cervix.  The  deformity  may  be  discovered  accidentally, 
or  the  patient  may  complain  of  marital  difficulty.  If  causing  no  dis- 
ability, it  should  be  left  untreated  ;  otherwise  the  longitudinal  septum 
should  be  removed  and  the  two  halves  of  the  vagina  joined  by  sutures. 

VAGINAL    SEPTA 

Occasionally  an  annular  septum  occurs  in  the  vagina,  giving  rise 
to  dyspareunia.  It  must  be  cut  away  if  causing  inconvenience  ;  other- 
wise it  should  be  let  alone. 

VAGINAL   FISTUL.E 

Vesico-vaginal  fistulse  occur  as  a  result  of  prolonged  labour  or  of 
operative  procedures.  Uretero-vaginal  fistulae  are  occasionally  met 
with  after  total  hysterectomy.  Recto-vaginal  fistulae  result  either  from 
laceration  during  childbirth  or  from  an  abscess  in  the  recto-vaginal 
septum. 

Treatment. — A  vesico-vaginal  fistula  may  be  dealt  with  either 
by  simply  paring  the  edges  and  drawing  them  together  by  suture,  or, 
when  large  or  intractable,  by  separating  the  bladder  and  vaginal  walls 
and  suturing  the  aperture  in  each  separately.  In  some  cases  it  may 
be  necessary  to  deflect  a  flap  from  the  adjacent  part  of  the  vaginal  wall 
to  cover  the  deficiency,  or  the  upper  part  of  the  vagina  can  be  detached 
from  the  lower  portion,  closed,  and  left  as  an  annexe  of  the  bladder 
(colpocleisis).  If  these  methods  fail,  the  abdomen  should  be  opened, 
the  bladder  separated  from  the  vagina,  and  the  apertures  in  each 
closed.  It  is  absolutely  necessary  to  cure  cystitis,  if  it  exists,  before 
performing  any  operation. 

A  ureteric  fistula,  if  the  communication  of  the  ureter  with  the 
bladder  is  still  maintained,  may  be  treated  by  paring  and  suturing. 
3  / 


994  THE   VAGINA 

but  otherwise  must  be  dealt  with  by  implantation  of  the  injured  duct 
into  the  bladder  or  removal  of  the  corresponding  kidney.  Recto- vaginal 
fistulse  should  be  sutured. 

CYSTOCELE 

A  cystocele  is  a  protrusion  of  the  anterior  vaginal  wall  and  bladder 
base  between  the  edges  of  the  two  levator  ani  muscles,  which  have 
become  divaricated  as  a  result  of  childbirth. 

Etiology. — Inadequacy  of  the  perineum  nearly  always  coexists. 
The  protrusion,  though  a  result  of  parturition,  does  not  commonly 
follow  that  event  for  some  years.  It  is  usually  seen,  like  uterine  pro- 
lapse and  rectocele,  with  which  it  is  often  associated,  in  women 
approaching  the  forties — the  stretching  of  the  tissues,  which  at  first  is 
very  slow,  being  accelerated  by  the  loss  of  muscular  tone  that  accom- 
panies advancing  years. 

Clinical  features. — The  patient  complains  of  "  something 
falling,"  or  "  the  womb  falling,"  though  the  uterus  may  not  be  dis- 
placed. The  protrusion  is  a  source  of  soreness  or  pain,  and  sometimes 
of  micturitional  troubles,  usually  partial  incontinence. 

Diagnosis. — The  pink  rounded  protrusion  could,  after  digital 
examination,  only  be  confused  with  a  lax  cyst  of  the  anterior  vaginal 
wall,  which  is  a  rarity.  A  sound  in  the  bladder  can  be  felt  under  the 
vaginal  wall  if  the  swelling  be  a  cystocele,  but  not  if  it  be  a  cyst. 

Treatment. — Cystocele  may  be  treated  (1)  by  pessaries,  (2)  by 
perineoplasty,  or  (3)  by  anterior  colporrhaphy. 

1.  Pessaries. — If  an  operation  is  not  possible  or  advisable  by 
reason  of  the  patient's  refusal,  her  age  or  general  condition,  or  the 
likelihood  of  further  labours,  a  rubber  ring  or  a  Hodge's  pessary  should 
be  inserted. 

2.  Perineoplasty. — If  the  patient  should  not,  cannot,  or  will 
not  wear  a  pessary,  a  well-performed  perineoplasty  (p.  1C03)  usually 
suffices  to  prevent  the  protrusion.  The  new  perineum  must  extend 
forwards  so  as  completely  to  screen  the  vaginal  orifice.  In  other 
cases,  though  it  does  not  prevent  the  protrusion  altogether,  it  allows 
of  the  retention  of  a  pessary,  previously  impossible. 

3.  Anterior  colporrhaphy. — An  oval  area  of  the  protruded 
vaginal  wall,  with  its  long  axis  in  that  of  the  vagina,  is  excised,  and 
the  fasciae  (triangular  ligaments)  underlying  it  are  divided  so  as  to 
separate  the  bladder  base  from  the  vaginal  wall  very  freely  around 
the  margins  of  the  incisions,  and  allow  it  to  ride  upwards  before  the 
wound  is  sutured.  The  gap  in  the  fascia?  is  then  sutured  transversely, 
and  the  gap  in  the  vaginal  mucosa  longitudinally.  A  more  elaborate 
procedure  consists  in  dissecting  outwards  from  the  margins  of  the 
incision  until  the  edges  of  the  levatoree  ani  are  reached,  and  suturing 


REGTOCELE  -VAGINITIS  995 

these  together  in  the  middle  line  under  the  bladder  before  the  vaginal 
wound  is  dosed.  In  either  case,  perineoplasty  musl  be  performed 
as  well,  or  the  condition  will  recur. 

HECTOCBLE 

A  cectocele  is  a  protrusion  of  the  recto-vaginal  Beptum  and  posterior 

vaginal  wall  through  the  vaginal  orifice.  It  is  constantly  associated 
with  a  deficient  perineum,  and  frequently  with  cystocele  and  prolapse 

of  the  uterus. 

Etiology. — The  deformity  is  due  to  two  factors — (1)  deficiency 
of  the  perineum,  (2)  relaxation  of  the  posterior  part  of  the  pelvic  floor. 
The  rectum  falls  forwards  on  the  posterior  vaginal  wall,  which,  unsup- 
ported by  a  perineum,  stretches  and  protrudes. 

Clinical  features. — The  patient  complains  of  "something 
falling."  In  most  cases  cystocele  is  present  as  well.  The  protruded 
mass,  when  large,  may  become  very  sore  or  even  ulcerated  from  the 
friction  of  the  clothes. 

Diagnosis. — On  inspection  it  may  be  impossible  to  tell  whether 
the  pink  swelling  is  a  cystocele  or  a  rectocele,  but  digital  examination 
will  immediately  decide  the  question. 

Treatment. — A  pessary  may  be  employed  to  retain  the  redundant 
vaginal  wall,  but  if  the  perineum  is  deficient  it  may  be  impossible  to 
keep  the  instrument  in  place.  The  best  treatment  is  perineoplasty, 
perhaps  combined  in  severe  cases  with  excision  of  a  portion  of  the 
posterior  vaginal  wall  (posterior  colporrhaphy). 

INFLAMMATION   OF   THE   VAGINA 

■  VAGINITIS 
Inflammation  of  the  vagina  is  best  classified  according  to  its  cause, 
as  follows  : — 

Streptococcal  and  Pneumococcal  Vaginitis   (Erysipelatous  or 
Gangrenous  Vaginitis) 

This  is  chiefly  seen  in  some  of  the  more  virulent  forms  of  puerperal 
sepsis.  The  appearance  varies,  the  surface  being  erysipelatous,  diph- 
theroid, or  frankly  sloughing. 

Treatment  is  that  of  streptococcal  infections  generally. 
Hydrogen  peroxide  (10  vols.)  is  the  best  application  if  necrosis  has 
occurred,  otherwise  biniodide  of  mercury  solution  (1-2,000)  should 
be  used. 

Staphylococcal  Vaginitis  (Simple  Vaginitis) 

Simple  vaginitis  may  be  due  to  injuries,  operations,  excessive 
chemical  applications,  the  prolonged  wearing  of  foul  pessaries,  or  the 


996  THE   VAGINA 

presence  of  other  foreign  bodies.  Occasionally  it  is  seen  in  virgins 
without  obvious  cause. 

The  surface  is  red,  smarting  and  painful,  and  a  purulent  discharge 
flows  from  the  vagina.  The  cervical  canal  is  often  infected  as  well, 
and  is  apt  to  remain  inflamed  long  after  the  vagina  has  recovered  ; 
by  persistent  re-infection  it  may  render  treatment  directed  to  the 
vagina  alone  of  no  avail,  particularly  in  the  vulvo-vaginitis  of  children. 

Diagnosis. — This  is  made  absolute  by  bacteriological  examina- 
tion of  the  pus.  The  possibility  of  gonorrhceal  origin  must  never  be 
mentioned  until  bacteriological  proof  has  been  obtained.  The  vulvo- 
vaginitis of  children,  while  sometimes  gonococcal,  is  usually  staphylo- 
coccal, but  parents  are  almost  uniformly  apt  to  assume  the  graver 
infection. 

Treatment. — Simple  antiseptic  douching  usually  suffices.  In 
virgins,  and  particularly  in  children,  the  hymen  may  hinder  douching, 
and,  by  obstructing  drainage,  maintain  the  inflammation.  Where  an 
ordinary  douche  tube  cannot  be  inserted  a  glass  catheter  may  be  used. 

Gonococcal  Vaginitis 

The  clinical  features  and  treatment  of  this  condition  are  discussed 
in  Vol.  I.,  pp.  832-34.  The  disease  runs  a  more  severe  course  where 
the  hymen  is  practically  intact,  because  drainage  and  medication  are 
alike  interfered  with.  The  hymen  becomes  swollen,  scarlet,  and  so 
sensitive  that  any  attempt  to  pass  a  douche  nozzle  causes  severe  pain. 

Complications. — Bartholin's  gland  often  suppurates.  Exten- 
sion of  the  infection  to  the  body  of  the  uterus  and  to  the  Fallopian 
tubes  is  common,  but  does  not  usually  occur  for  several  weeks  after 
the  initiation  of  the  attack.  Gonorrhceal  cystitis  is  also  frequently 
met  with. 

Diagnosis. — No  definite  statement  should  be  made  unless  sup- 
ported by  bacteriological  proof ;    even  then  caution  is  to  be  observed. 

The  treatment  of  the  complications  of  gonorrhoea  generally  has 
already  been  considered  (Vol.  I.,  p.  836).  During  the  acute  stage, 
urinary  antiseptics  should  be  given  to  prevent  cystitis. 

NEW   GROWTHS   OF    THE    VAGINA 

CYSTS 

Although  the  vaginal  wall  normally  contains  no  glands,  small 
aberrant  glandular  retention  cysts  are  occasionally  found  there.  They 
rarely  exceed  the  size  of  a  pea.  A  rare  condition,  adenomatosis  vagina, 
in  which  the  whole  vaginal  wall  is  beset  with  glands,  has  been  described 
by  the  author  and  Glendinning.1 

]  Proc.  Roy.  Soc.  Med.,  vol.  iv. 


VAGINAL   TUMOURS  997 

Thin-walled  cysts  sometimes  occur  od  the  lateral  or  lower  pari  «>t 
the  anterior  vaginal  wall.  These  are  Wolffian  in  origin,  and  have 
been  found  extending  up  into  the  broad  ligamenl  in  the  course  of 

Gartner's   duct. 

The  cyst   should  be  excised  if  it   is  causing  trouble. 

SOLID  TUMOURS,   ENNOCENT   AND   MALIGNANT 

Solid  tumours  of  the  vagina  are  very  rare.  Myomas  are  most 
often  encountered.  They  appear  as  rounded  hard  tumours  bulging 
into  the  lumen  of  the  canal,  and  covered  by  the  mucous  membrane 
lining  it.     Papillomas  and  soft  fibromas  occur  occasionally. 

Malignant  disease  is  uncommon  in  the  vagina.  Squamous-celled 
carcinoma  may  be  primary  there  or  secondary  to  a  growth  in  the 
cervix.  It  assumes  the  form  of  a  nodular  ulceration.  Adeno-carci- 
noma  secondary  to  carcinoma  of  the  corpus  is  sometimes  seen.  Me- 
tastatic nodules  of  chorion-epithelioma  are  relatively  common  in  the 
course  of  this  interesting  disease,  and  in  addition  a  good  number 
of  cases  are  recorded  in  which  this  variety  of  malignant  disease  has 
appeared  there  primarily. 

Sarcoma  of  the  vagina  occurs  both  in  children  and  in  adults.  In 
the  former  it  assumes  the  same  "  grape-like  "  appearance  that  charac- 
terizes infantile  sarcoma  of  the  cervix.  In  adults  it  presents  as  a  soft, 
red,   "  velvety  "-surfaced  mass.     Both  types  are  exceedingly  rare. 

Symptoms. — The  innocent  growths  may  give  rise  to  no  symptoms, 
or,  by  their  size,  may  cause  marital  difficulty  or  pain.  The  malignant 
tumours  present  the  clinical  features  common  to  them  elsewhere. 

Treatment — The  innocent  tumours  should  be  removed. 
Vaginal  myomas  are  well  encapsulated,  and  shell  out  easilv. 

Malignant  disease  of  the  vagina  is  a  very  serious  matter,  owing  to 
the  readiness  with  which  it  spreads  to  the  rectum  or  bladder,  and  the 
frequency  with  which  it  is  already  inoperable  when  the  patient  presents 
herself.  Where  limited  to  the  vagina,  the  growth  demands  total 
removal  of  this  canal  together  with  the  uterus — total  hystero-vaginectomij 
(see  under  Carcinoma  of  the  Cervix,  p.  1<  322).  Where  a  small  primary 
growth  exists  close  to  the  outlet,  the  lower  part  of  the  vagina  alone  may 
be  excised,  and  the  upper  portion  pulled  down  and  united  to  the  skin. 

THE  UTERUS 
DEFORMITIES  AND  DISPLACEMENTS 

ABSENCE    OF    THE    UTERUS 

The  uterus  may  be  absent  altogether.  Such  deformity  is  usually  asso- 
ciated with  more"  or  less  deficiency  of  the  vagina  and  maldevelopment  of  the 
ovaries. 


998  THE   UTERUS 

ATRESIA    OF    THE    CERVIX 

The  cervix  may  become  imperforate  as  a  result  of  the  application 
of  strong  caustics.  Rarely  it  is  congenitally  so.  In  either  case,  if  the 
uterus  be  functional,  retention  of  menstrual  blood  occurs.  The  site 
of  retention  varies  ;  if  the  obstruction  be  limited  to  the  external  os, 
the  cervix  is  distended  first  (hcematotrachelos),  and  later  the  tubes' ;  if 
the  obstruction  be  at  the  internal  os,  hematosalpinx  is  usually  the 
first  event,  the  uterus  distending  subsequently.  The  clinical  features 
are  those  of  retained  menses  with  symptoms  of  hematosalpinx  and 
salpingitis.  Communication  with  the  vagina  should  be  established  if 
possible.  If,  however,  this  cannot  be  done,  or  if  the  tubes  are  already 
disorganized,  removal  of  the  uterus  and  tubes  is  indicated. 

DOUBLE  UTERUS  (Fig.  580) 

The  following  degrees  of  double  uterus  depend  on  the  extent  to 
which  the  Mullerian  ducts  have  failed  to  fuse  : — 

1.  Uterus  duplex. — Two  distinct  organs.  A  peritoneal  fold  from 
rectum  to  bladder  passes  between  them. 

2.  Uterus  bicornis  unicollis. — Two  bodies  joined  to  a  single  neck. 

3.  Uterus  unicornis. — A  bicornuate  uterus  in  which  only  one  body 
has  developed,  the  other  remaining  as  a  narrow  tube. 

4.  Uterus  septus. — The  uterus  is  outwardly  single  and  of  normal 
shape,  but  a  longitudinal  septum  divides  its  cavity  down  to  the 
external  os. 

5.  Uterus  subseptus. — A  similar  condition  to  No.  4,  but  the  septum 
only  reaches  the  internal  os. 

Clinical  features. — The  deformity  usually  causes  no  symp- 
toms, and  is  only  accidentally  discovered.  Though  any  uterine 
deformity  militates  against  conception,  repeated  pregnancy  has 
occurred  in  one  half  of  a  double  uterus  ;  a  decidua  is  formed  in  the 
unimpregnated  half,  and  is  expelled  after  the  labour. 

Pregnancy  sometimes  occurs  in  the  undeveloped  horn  of  a  unicorn 
uterus  and  runs  the  same  course  as  pregnancy  in  the  Fallopian  tube, 
except  that  rupture  is  less  common  and  a  greater  proportion  of  the 
cases  go  on  to  term. 

Hsernatometra  in  one  half  of  a  double  uterus  is  occasionally  met 
with,  the  symptoms  being  those  of  recurring  monthly  pain  and  a 
cystic  tumour  to  one  side  of  the  apparently  unenlarged  uterus.  There 
is,  of  course,  no  amenorrhcea.  Septate  uteri  have  been  discovered 
during  mechanical  dilatation  of  the  organ,  the  edge  of  the  partition 
obstructing  the  passage  of  the  dilator.  The  half  of  a  bicornuate 
uterus  has  been  found  in  the  sac  of  an  inguinal  hernia,  in  the  male 
as  well  as  the  female  (internal  pseudo-hermaphrodism). 


DOUHLi:    I'TKKIS 


999 


Diagnosis.  —Where  two  cervices  exist,  the  diagnosis  is  obvious. 
With  a  single  cervix,  double  bodies  may  be  detected  l>v  bimanual 
examination.  They  sweep  outwards  in  a  characteristic  manner  parallel 
with  Poupart's  ligament.     The  passage  of  the  sound  will  tender  the 

condition  clear. 

A  uterus  unicornis  may  be  suspected  from  the  presence  of  the 
peculiar  outward  sweep  already  mentioned,  and  only  one  uterus  cas 
be  felt. 

Pregnancy  in  an  undeveloped  horn  can  only  be  distinguished  from 


Fig.  580. — Double  uterus. 

The  left  horn  contains  a  myoma.     The  septum  dividing  the  vagina  into  two  halves  is  shown. 


a  tubal  pregnancy  by  noting  the  relation  borne  by  the  tumour  to  the 
round  ligament,  i.e.  the  ligament  terminates  in  its  outer  side. 

Haematometra  of  an  undeveloped  horn  may  be  suspected  from 
a  consideration  of  the  history,  the  youth  of  the  patient,  and  the  extreme 
lateroversion  of  the  recognizable  body  of  the  uterus. 

Treatment. — If  symptoms  are  absent  nothing  need  be  done ; 
otherwise  the  uterus  or  the  cornu  at  fault  should  be  removed. 

ELONGATION    OF    THE    VAGINAL    CERVIX 
There  are  two  main  types  of  elongation  of  the  vaginal  cervix  : 
(1)  a  so-called  "  congenital  "  elongation,  occasionally  seen  in  young 
women,  in  which  the  vaginal  cervix,  though  so  elongated  as  to  protrude 


iooo  THE   UTERUS 

perhaps  from  the  vulva  like  a  polyp,  is  extremely  thin,  and  (2)  the 
acquired  elongations  most  commonly  due  to  chronic  hyperplastic 
cervicitis,  but  more  rarely  to  the  development  of  a  myoma,  a  car- 
cinoma or  sarcoma,  or  large  cyst  in  the  cervical  wall.  In  these 
cases  the  vaginal  cervix  is  enlarged  in  every  dimension. 

Clinical  features. — The  congenital  form  may  produce  no 
symptoms  and  may  be  discovered  accidentally.  In  the  acquired 
variety  the  patient  becomes  aware  of  an  abnormal  mass  filling  the 
vagina  or  protruding  from  the  orifice,  and  complains  of  a  sense  of 
dragging  or  bearing  down.  If  cervicitis  be  present,  there  will  be  leu- 
corrhoea,  pain  in  coitus,  and  occasional  slight  blood-stained  discharges. 

Diagnosis. — The  congenital  form  may  be  mistaken  for  a  polyp, 
but  inspection  of  the  most  dependent  part  of  the  protrusion  will 
show  the  external  os,  and  careful  vaginal  examination  will  clinch 
the  diagnosis. 

General  hypertrophy  due  to  inflammation  or  new  growth  could  only 
be  mistaken  for  a  tumour  extruding  through  the  external  os,  or  for 
the  body  of  a  totally  inverted  uterus  ;  careful  examination  will  not  fail 
to  distinguish  it  from  these  conditions. 

Treatment. — The  congenital  elongation  should  not  be  interfered 
with  unless  it  causes  annoyance  or  produces  sterility ;  in  such  case  it 
may  be  amputated  circularly  just  below  the  vaginal  vault.  An  acquired 
hypertrophy  must  be  treated  according  to  its  cause.  "When  it  is  due 
to  cervicitis,  circular  amputation  or  tracheloplasty  (p.  1011)  may  be 
performed  ;  when  it  is  the  result  of  new  growth,  the  appropriate 
treatment  must  be  carried  out. 

PROLAPSE    OF   THE    UTERUS 
Etiology. — Rarely  prolapse  is  present  at  birth,  whilst  occasion- 
ally it  is  met  with  in  young  virgins.     In  either  case  the  deformity 
is  due  to  congenital  deficiency  of  the  sustentacular  apparatus. 

In  the  vast  proportion  of  cases,  however,  prolapse  of  the  uterus  is 
the  result  of  childbearing.  The  structures  fixing  the  uterus  and  vagina 
in  their  normal  position  may  be  divided  into  three  groups  : — 

1.  Upper  supporting  structures. — These  constitute  the  upper  part  of 
the  broad  ligaments,  and  comprise  the  peritoneal  folds,  the  ovarico- 
pelvic  and  ovarico-uterine  ligaments,  the  perivascular  sheaths  of  the 
ovarian  vessels  and  the  round  ligaments.  Though  the  single  elements 
have  no  great  resisting  power,  yet  taken  en  masse  they  form  a  support 
of  considerable  strength. 

2.  Middle  supporting  structures. — These  consist  of  two  pairs  of  fibro- 
cellular  bands  uniting  the  upper  part  of  the  vagina  and  supravaginal 
cervix  to  the  sacrum  and  lateral  pelvic  walls  respectively. 

The  posterior  pair,  together  with  their  covering  peritoneum,  form 


UTERINE    PROLAPSE  ioci 

the  utero-sacral  ligaments  ;  the  very  Btrong  lateral  pair  lie  in  the  base 
of  the  broad  ligamenl  and  ate  known  as  Mackenrodt's  oi  the  lateral 
cervico-pelvic  ligaments.  At  their  upper  edges  run  the  uterine  arteries 
ami  the  ureters. 

3.  Lower  supporting  structures.—  These  make  up  the  pelvic  floor 
proper,  and  consist  of  the  recto-vesical  fascia,  i  he  levatores  ani,  and  I  he 
superficial  perineal  muscles  and  fasciae.  The  horseshoe-shapi.!  gap 
between  the  levatores  is  filled  in  by  the  triangular  ligaments,  which 
are  perforated  by  the  vagina  and  urethra,  while  the  fascia  of  Colles  is 
cleft  by  the  vulva. 

The  edges  of  the  levatores  ani  muscles  are  in  relation  with  the 
lateral  vaginal  walls  at  a  point  less  than  an  inch  up  that  canal,  so  that 
mosl  of  the  vagina  and  all  the  uterus  is  well  above  the  pelvic  floor, 
which,  therefore,  only  indirectly  supports  the  latter  organ. 

With  the  uterus  anteverted  and  the  perineal  body  intact,  the 
genital  canal  forms  a  sharp  curve,  concave  forwards.  This  curve 
plays  a  very  important  part  in  the  support  of  the  uterus,  which  in 
the  standing  posture  rests  upon  the  pubis,  the  bladder  intervening, 
whilst  in  recumbency  it  stands  nearly  vertical  on  the  structures 
lying  in  the  hollow  of  the  sacrum. 

Uterine  prolapse  is  due  to  weakening  more  or  less  of  the  whole 
retentive  apparatus,  for  such  is  the  reserve  power  of  its  various  con- 
stituents that  failure  of  one  group  alone  is  insufficient  to  cause  descent 
of  the  organ  if  the  others  remain  healthy.  Thus  absolute  flaccidity  of 
the  upper  supports  is  constantly  seen  with  retroversion,  but  without 
prolapse  ;  and  extensive  cystocele  and  rectocele  due  to  bulging  of  the 
pelvic  floor  may  coexist  with  a  uterus  in  normal  position. 

Prolapse  of  the  female  genital  canal  may  be  classified  under  two 
main  types,  according  to  whether  the  eversion  begins  (1)  from  below 
upwards,  or  (2)  from  above  downwards. 

In  the  first,  the  pelvic  floor  proper  is  primarily  at  fault,  and  the 
descent  of  the  uterus  is  preceded  by  cystocele  and  rectocele.  The 
levatores  ani  are  separated  and  the  perineal  body  and  normal  vaginal 
curve  are  absent. 

In  the  second  type,  a  primary  yielding  of  the  upper  and  middle 
supports  allows  the  uterus  to  drop  through  the  vagina,  the  cervix  first 
protruding  at  the  vulva  and  being  followed  by  the  vaginal  walls  as 
they  evert  from  above  downwards. 

Where  the  fault  primarily  lies  with  the  pelvic  floor  the  upper 
part  of  the  broad  ligaments  and  the  utero-sacral  and  lateral  cervico- 
pelvic  ligaments  resist  the  tendency  to  downward  descent,  with  the 
result  that  the  vagina  is  longitudinally  stretched ;  but  if  the  primary 
weakness  lies  with  the  utero-sacral  and  lateral  cervico-pelvic  liga- 
ments, the  upper  part  of  the  broad  ligament    resists   the  downward 


ioo2  THE   UTERUS 

pull  and  the  supravaginal  cervix  becomes  elongated,  so  that  the 
external  os  may  possibly  appear  at  the  vulva  while  the  fundus 
of  the  uterus  remains  at  its  normal  level. 

Uterine  prolapse  is  aided  by  high  intra-abdominal  pressure,  and 
therefore  its  occurrence  often  coincides  with  the  adipose  and  flatulent 
distension  of  advancing  years. 

Theoretically,  increased  weight  of  the  organ  should  favour  prolapse, 
but  considerable  enlargement  prevents  descent  through  the  pelvis, 
and,  as  a  matter  of  fact,  many  a  prolapsed  uterus  is  smaller  than 
normal.  Very  rarely,  large  polypoid  tumours  of  the  uterus  have  dragged 
the  organ  after  them  in  their  descent  from  the  vagina. 

Clinical  features.— Three  degrees  of  prolapse  of  the  uterus  are 
recognized — (1)  where  the  cervix  is  still  within  the  vagina,  (2)  where 
the  cervix  protrudes  from  the  vagina,  (3)  where  the  whole  uterus  is 
outside  the  vagina,  the  latter  canal  being  turned  inside  out. 

The  symptoms  may  begin  shortly  after  childbirth,  but  most  com- 
monly not  till  some  years  later.  A  sense  of  weight,  bearing  down  and 
backache  is  complained  of,  with  vesical  irritability  or  partial  incon- 
tinence of  urine.  The  procident  part,  when  it  emerges  from  the  vagina, 
becomes  chafed,  scaly  and  dry,  and  later  ulcerated.  The  ulcers  are 
typically  "  callous,"  with  a  firm  smooth  white  edge.  They  cause 
soreness  as  a  rule,  but  are  liable  to  acute  attacks  of  inflammation, 
during  which  they  may  suppurate  freely,  or  even  slough,  with  much 
pain  and  some  constitutional  disturbance.  Though  often  mistaken 
for  carcinoma,  they  very  rarely  undergo  malignant  degeneration. 

Diagnosis. — The  patient  should  be  examined  in  the  standing 
posture  for  all  "  gravity  "  displacements. 

Elongation  of  the  vaginal  cervix  and  complete  inversion  of  the 
uterus  are  the  only  conditions  with  which  prolapse  of  the  uterus  could 
reasonably  be  confounded.  In  neither  of  those  cases  is  the  vaginal 
vault  lowered,  whereas  in  prolapse  of  the  uterus  this  change  is  con- 
stantly observed.  The  absence  of  the  external  os  would  at  once 
disclose  an  inversion. 

Treatment.  Pessaries. — Treatment  by  pessary  is  proper  for 
patients  in  whom  age,  debility,  or  the  probability  of  further  labours 
contra-indicates  operation,  and  in  those  who  refuse  operation  or  to 
whom  the  time  entailed  means  loss  of  employment. 

The  rubber  ring  is  the  most  generally  useful  pessary.  In  a  few 
cases  of  slight  prolapse,  the  continued  retention  of  the  uterus  in  proper 
position  for  some  months,  or  a  year  or  two,  may,  by  allowing  the  uterine 
supports  to  recover  themselves,  actually  effect  a  cure.  In  most  cases, 
however,  the  treatment  is  merely  palliative.  Women  wearing  a  pessary 
must  be  instructed  to  douche  at  least  once  a  day,  and  to  have  the 
instrument  changed  every  three  months. 


UTKRINK    PROLAPSE:   TREATMENT  1003 

Where  no  perinea]  body  exists,  and  also  in  the  coniform  vagina 
of  old  age,  no  ordinary  pessary  can  be  retained.  In  these  cases,  if 
perineoplasty  be  contra-indicated  or  refused,  some  form  of  vaginal 
stem  pessary  must  he  worn,  such  as  Napier's  or  Maw's.  These  arc 
of  great  service  in  feeble,  elderly  women. 

Operative  treatment. — Combined  perineoplasty  and  ventro-stu- 
j»nsion  of  ike  uterus  are  the  most  efficient  method  of  cure,  and  the 
operations  may  be  performed  under  one  ana'sthesia.  Perineoplasty 
by  itself  may  greatly  relieve  that  variety  of  prolapse  in  which  the 
descent  of  the  uterus  is  preceded  by  cystocele  and  rectocele,  and 
both  in  these  cases  and  those  in  which  the  uterus  primarily  descends 
it  enables  a  pessary  to  he  worn  if  this  was  previously  impossible. 
Ventro-suspension  alone  will  cure  the  rare  cases  of  primary  uterine 
descent  without  any  prolapse  of  the  vaginal  walls.  The  uterus  must 
be  fixed  as  high  up  the  anterior  abdominal  wall  as  possible,  so  as  to 
get  a  straight  pull  on  the  vagina  and  pelvic  floor.  Low  fixation  of 
the  uterus  increases  cystocele,   if  present. 

Many  otber  operations  have  been  designed  for  the  cure  of  prolapse. 
Colporrhaphy,  either  anterior  or  posterior,  may  be  combined  with 
perineoplasty,  where  great  redundancy  of  the  vaginal  wall  is  present. 
I  ntervesieo-vaginal  fixation  of  the  uterus  is  much  practised  on  the 
Continent  and  by  some  American  surgeons,  when  the  patient  is  past 
the  childbearing  age,  and  various  methods  of  suturing  together  the 
edges  of  the  levatores  ani  (myorrhaphy),  of  narrowing  the  vaginal  canal, 
or  of  plicating  or  suturing  together  the  lateral  cervico-pelvic  ligaments, 
have  been  devised.  All  of  them,  in  my  opinion,  are  inferior  to  ventri- 
fixation  and  perineoplasty  in  combination. 

Success  has  been  reported  by  Inglis  Parsons  from  injecting  into  the 
bases  of  the  broad  ligaments  per  vaginam  a  l-in-5  solution  of  quinine. 
A  degree  of  broad-ligament  cellulitis  is  thereby  set  up,  which  fixes  the 
uterus.  The  method  may  well  be  tried  where  a  regular  operation  is 
contra-indicated  or  objected  to. 

Hysterectomy  should  never  be  done  for  prolapse  ;  by  severing  the 
connexion  between  the  vagina  and  the  broad  ligaments,  it  facilitates 
eversion  of  that  canal  so  much  that  the  whole  vagina  turns  inside  out. 
Digital  examination  of  the  prolapsed  parts  in  total  procidentia  will 
show  how  small  a  proportion  of  the  mass  is  formed  by  the  uterus  itself. 
Instead  of  removing  the  organ,  it  should  be  utilized  as  an  artificial 
support  of  the  vagina  and  pelvic  floor  by  fixing  it  high  up  on  the  anterior 
abdominal  wall. 

Perineoplasty  is  performed  by  dissecting  up  a  flap  from  the  posterior 
vaginal  wall  and  excising  it  in  the  shape  of  a  V.  The  edges  of  the  V 
are  then  united  by  suture  to  restore  the  normal  forward  curve  of  the 
canal.     The  skin  wound  is  closed  either  by  a  single  layer  of  deep  silk- 


ioo4  THE   UTERUS 

worm-gut  sutures  or  in  layers  of  catgut  uniting  (1)  the  edges  of  the 
levator  ani,  (2)  the  superficial  fascial  planes,  and  (3)  the  skin.  If 
the  rupture  extends  through  the  anus  the  recto-vaginal  septum  must 
be  split  before  the  vaginal  flap  is  turned  up.  The  gap  in  the  wall  of 
the  bowel  is  closed  separately  by  buried  catgut  sutures. 

RETROVERSION    OF    THE    UTERUS 

The  uterine  axis  varies  greatly  in  direction  within  normal  limits, 
being  affected  by  the  state  of  the  intestines  and  the  bladder,  and  the 
position  of  the  patient.  Various  arbitrary  degrees  of  retroversion  have 
been  described,  which  serve  no  useful  purpose,  and  should  be  dis- 
carded in  place  of  this  simple  rule  :  if,  with  the  patient  in  the  standing 
posture,  the  axis  of  the  uterus  is  directed  behind  the  vertical,  the  uterus 
is  retroverted. 

Doubtful  cases  of  displacement  must  always  be  examined  with  the 
patient  erect,  for  many  a  uterus  that  is  retroverted  in  dorsal  decubitus 
takes  up  the  normal  anteverted  position  when  the  patient  stands. 
Such  patients  need  no  treatment  for  the  retroversion. 

Retroflexion  is  always  secondary  to  retroversion  ;  the  flaccid  uterus 
bends  just  above  the  attachment  of  the  utero-sacral  and  lateral  cervico- 
pelvic  ligaments. 

Etiology. — Retroversion  is  caused  by  yielding  of  the  upper 
part  of  the  broad  ligaments,  and  this  may  arise  in  several  ways  : — 

1.  Gravity. — An  abnormally  heavy  uterus  may  retrovert  of  its  own 
weight,  as  in  some  cases  of  myoma  ;  on  the  other  hand,  a  normal 
organ  may  stretch  ligaments  already  weak  from  parturition,  maldevelop- 
ment,  or  general  debility.  The  coexistence  of  a  heavy  uterus  and 
relaxed  ligaments  such  as  occurs  in  puerperal  subinvolution  is  the 
commonest  cause  of  retroversion. 

2.  Pressure. — Large  tumours  lying  in  front  of  the  uterus  may  push 
the  organ  into  retroversion.  This  often  occurs  with  ovarian  cysts  and 
myomas. 

3.  Traction. — The  contraction  of  adhesions  may  pull  the  uterus  into 
retroversion.  This  is  often  seen  in  chronic  salpingitis,  and  particularly 
after  bilateral  salpingo-oophorectomy  for  inflammatory  conditions, 
where  the  operation  has  interfered  with  the  normal  supporting  structures. 

4.  Trauma. — Probably  sudden  falls  or  strains  may  cause  retrover- 
sion, though  this  is  impossible  of  proof.  It  is  the  most  reasonable 
explanation  of  the  commonly-found  cases  in  virgins,  and  in  many 
instances  the  history  strongly  supports  such  a  view. 

Effect  of  retroversion  on  the  uterus. — It  is  doubtful  if 
retroversion  per  se  has  any  effect  on  a  healthy  uterus,  for  in  virgins 
this  displacement  commonly  occurs  without  any  signs  of  uterine  disease. 
Most  cases  of  retroversion  are,  however,  puerperal  in  origin,  and  in 


RETROVERSION  1005 

(linn  the  uterus  is  usually  enlarged  and  often  chronically  inflamed  as 

the  resnll  of  the  faulty  puerperium  in  which  the  displacemenl  originated. 

Prolonged  retroversion  ol  ;i  large  uterus  frequently  causes  a  white 

patch  of  thickened  peritoneum  on  its  posterior  surface,  due  to  diction. 

Probably  tins  friction  sometimes  leads  to  filamentous  adhesion 
these  are  often  found  without   any  evidence  of  salpingitis.     Chronic 

salpingitis  i<.  however,  often  associated  with  retroversion  as  an 
extension  from  the  puerperal  endometritis  present  before  the  dis- 
placement. 

Clinical  features. -.Many  cases  of  retroversion  exist  with- 
out symptoms,  especially  where  the  uterus  is  small  ami  only  the  upper 
uterine  supports  are  lax.  Where  the  uterus  is  heavy  and  the  rest  of  the 
suspensory  apparatus  weak,  as  in  most  cases  of  puerperal  origin,  back- 
ache and  abdominal  pain  radiating  outwards  parallel  to  Poupart's  liga- 
ment are  felt,  due  to  traction  on  the  utero-sacral  and  broad  ligaments 
respectively.  These  pains  are  worse  at  the  periods,  and  after  standing, 
but  are  not  entirely  relieved  by  lying  down,  as  is  the  case  in  uterine 
prolapse.  Dyspareunia  is  common,  the  result  either  of  the  accom- 
panying prolapse  of  the  appendages,  or  of  chronic  peritonitis  and  fila- 
mentous adhesions  at  the  back  of  the  uterus.  Rectal  symptoms  may 
occur.  Inasmuch  as  a  retroverted  uterus  is  often  chronically  enlarged 
by  inflammation  and  subinvolution,  leucorrhcea,  menorrhagia,  and  a 
tendency  to  sterility  are  frequent.  Should  pregnancy  occur,  it  is 
unlikely  to  proceed  beyond  the  third  month  ;  indeed,  this  displacement 
is  the  commonest  cause  of  repeated  miscarriage.  If  miscarriage  does 
not  take  place,  the  uterus  nearly  always  rises  from  the  pelvis  and 
straightens  itself,  and  may  remain  in  proper  position  after  the  labour. 
In  a  few  cases  incarceration  results,  with  retention  of  urine  and  severe 
pressure  symptoms.  These  cases  of  incarcerated  retroverted  gravid 
uterus  with  a  distended  bladder  have  again  and  again  been  mistaken 
for  ovarian  cysts  through  neglect  to  use  the  catheter. 

Treatment. — Retroversion,  per  se,  needs  no  meddlesome  inter- 
ference, especially  in  virgins.  If,  however,  the  displacement  is  causing 
definite  discomfort  it  should  be  treated. 

Pessaries. — It  is  not  sufficient  that  the  organ  be  movable  or  even 
replaceable,  it  must  be  retainable,  to  justify  the  use  of  a  pessary. 
It  is  often  impossible  to  retain  a  perfectly  movable  uterus  in  anteversion, 
owing  to  permanent  alteration  in  the  length  of  t<he  peritoneal  folds  from 
prolonged  malposition.  Before  insertion  of  the  appliance,  the  organ 
must  be  brought  into  complete  anteversion,  i.e.  lying  almost  parallel 
with  the  anterior  vaginal  wall,  for  unless  all  coils  of  intestine  are  expelled 
from  the  utero-vesical  pouch,  retroversion  soon  recurs.  Moreover,  in 
this  position  gravity  assists  in  maintaining  the  anteversion,  whether  the 
patient  stand  or  lie.    Such  reposition  is  effected  by  manipulation,  either 


ioo6  THE    UTERUS 

alone  or  aided  by  the  uterine  sound.  If  the  organ  tends  to  roll  back 
wards  immediately  the  control  of  the  fingers  or  sound  is  withdrawn, 
the  introduction  of  a  pessary  is  contra-indicated,  for  its  slight  retaining 
power  is  inefficient  unless  assisted  by  gravity. 

Reposition  is  most  satisfactorily  carried  out  under  an  anaesthetic  ; 
and  where  cervicitis  or  endometritis  coexists,  the  unhealthy  mucosa 
should  be  curetted  at  the  same  time. 

Operations. — Of  the  many  operations  devised  for  retroversion, 
ventro-suspension  and  shortening  of  the  round  ligaments  are  the 
two  best. 

Ventro-suspension  consists  in  fastening  the  upper  part  of  the  anterior 
uterine  wall  to  the  anterior  abdominal  wall  by  three  or  four  sutures 
that,  picking  up  the  superficial  muscular  layers  of  the  former,  pass 
through  the  peritoneum  and  aponeurosis  on  either  side  of  the  wound. 
A  strong  peritoneal  adhesion  is  thus  formed,  which  gradually  stretches 
into  a  short  artificial  ligament  about  £  in.  long. 

Ventro-suspension  thus  performed  is  a  very  satisfactory  operation, 
and  does  not  interfere  with  subsequent  pregnancy.  Where,  however, 
real  fixation  of  the  uterus  has  been  performed,  or  where  the  fundus  or 
posterior  wall  or  one  of  the  cornua  has  been  attached  instead  of  the 
anterior  wall,  great  difficulties  both  in  pregnancy  and  in  labour  have 
been  experienced.  Cases  are  on  record  of  intestinal  obstruction  by 
the  artificial  ligament,  but  this  sequel  is  very  rare. 

Shortening  the  round  ligaments. — The  original  operation  devised  by 
Alexander  was  extraperitoneal,  the  ligaments  being  exposed  at  the 
external  abdominal  ring.  Since  only  cases  of  movable  retroversion 
could  be  so  treated,  the  operation  has  been  largely  given  up  in  favour 
of  intraperitoneal  ligamentopexy .  There  are  many  ways  of  performing 
this  operation.  The  most  ingenious  and  best  is  as  follows  :  The  abdo- 
men having  been  opened,  and  the  uterus  anteverted.  a  ligature  is  passed 
under  each  round  ligament  about  f  in.  from  its  uterine  attachment, 
and  tied,  the  ends  being  left  long.  A  special  curved  forceps  is  then 
inserted  through  a  little  slit  in  the  aponeurosis  \  in.  outside  the  edge 
of  the  wound,  and  is  pushed  outwards,  first  between  the  rectus  muscle 
and  aponeurosis,  and  subsequently  between  the  aponeurosis  and  peri- 
toneum, till  the  internal  abdominal  ring  is  reached.  The  point  of  the 
forceps  (still  extraperitoneal)  is  now  made  to  return  towards  the  middle 
line  under  the  peritoneum  of  the  broad  ligament  and  parallel  to  and 
just  in  front  of  the  round  ligament.  When  it  has  reached  the  position 
of  the  previously  applied  ligature  it  is  thrust  through  the  peritoneum 
and  the  ligature  ends  are  grasped  and  withdrawn  along  the  track  taken 
by  the  instrument. 

The  forceps  being  removed,  traction  is  made  upon  the  ligature  ends 
until  a  knuckle  of  round  ligament  appears  at  the  aponeurotic  slit. 


INVKRSION 


1007 


A  similar  proceeding  having  been  earned  cut  in  the  opposite  side 
knuckle  is  fixed  by  the  suture  closing  the  little  slit  in  the  aponeurosis 
on  us  own  side,  and  the  abdominal  wound  is  then  BUtured. 

This  proceeding  shortens  the  whole  of  the  front  part  of  the  broad 
ligament  on  either  side  and  leaves  the  uterus  in  a  truly  normal  position. 
li  1-.  therefore,  a  better  operation  than  ventro-suspension  for  retro- 
version, but  is  inadvisable  where  prolapse  also  exists,  as  it  does  not 
effect  a  sufficiently  direct    upward   pull  on  the  uterus. 

INVERSION    01    THE    UTERI'S 

This  rare  displacement  most  often  occurs  immediately  after  child- 
birth. Occasionally,  however,  cases  of  chronic  inversion  are  seen, 
with  an  obscure  relation  to  parturition.  .^me^         ^^. 

Three  degrees  of  inversion  are  described 
— (1)  where  the  inverted  fundus  is  still 
within  the  uterine  cavity ;  (2)  where  it 
is  extruded  from  the  external  os  ;  and  (3) 
where  the  entire  body  and  cervix  is  turned 
inside  out. 

Clinical  features. — The  accident, 
when  occurring  after  labour,  is  marked 
by  severe  shock  and  haemorrhage.  In 
chronic  cases  there  is  bearing-down  pain, 
with  bloody  discharge,  which  may  be 
offensive.  The  everted  uterine  mucosa 
becomes  ulcerated  or  may  superficially 
slough.     (Fig.  581.) 

Diagnosis. — The  mass  might  be  mis- 
taken   for    a   protruding  myoma,    but   careful   examination   and    the 
passage  of  a  sound  make  the  condition  clear. 

Treatment. — A  puerperal  inversion  must  be  at  once  reduced 
by  manipulation,  but  chronic  cases  can  rarely  be  so  treated.  The 
recognized  method  for  these  is  the  use  of  the  Aveling  repositor,  i.e.  a 
boxwood  cup  on  a  rigid  stem  which  is  kept  pressed  against  the  inverted 
fundus  by  indiarubber  straps  attached  to  a  waistband.  It  is  important 
to  place  tampons  around  the  repositor  to  keep  it  from  slipping  off  the 
mass  to  which  it  is  applied.  After  twenty-four  hours  it  will  usually  be 
found  that  the  displacement  has  been  corrected. 

If  the  repositor  fail,  the  utero-vesical  pouch  may  be  opened  from 
below,  and  the  everted  anterior  wall  of  the  uterus  incised  from  the 
cervix  downwards.  The  cupped  interior  of  the  inversion  is  thus  laid 
open,  the  adherent  appendages  which  prevent  its  reposition  are  freed, 
the  inversion  is  reduced,  and  the  wound  in  the  anterior  uterine  wall 
and  vaginal  cervix  subsequently  closed  by  sutures.     An  alternative 


Fig.  5S1. — Partial  inver- 
sion of  the  uterus. 


ioo8  THE   UTERUS 

proceeding  is  to  open  the  abdomen  and  incise  from  above  the  posterior 
wall  of  the  cup.  Finally,  the  inverted  uterus  may  be  removed  by 
vaginal  hysterectomy. 

INFLAMMATION  OF  THE   UTERUS 
ENDOCERVICITIS   AND    CERVICAL    "EROSION" 

Cervicitis  may  be  caused  by  direct  extension  upwards  of  a  vaginitis, 
or  may  be  part  of  a  general  uterine  infection  following  labour  or  abortion. 
It  may  also  follow  obstetric  lacerations  or  operative  wounds. 

The  normal  virgin  cervical  canal  is  probably  bacteriologically 
sterile.  The  vagina,  on  the  other  hand,  always  contains  organisms. 
The  vaginal  epithelium  is  remarkably  thick  and  resistant,  whilst  that 
of  the  cervix  is  reduced  to  a  single  layer  with  numerous  glandular 
crypts,  from  which  organisms,  once  lodged,  are  with  difficulty  eradicated. 

Cervicitis  may  undoubtedly  occur  in  chaste  virgins  from  an  ascend- 
ing bacterial  infection  from  the  germ- containing  vagina,  probably  due 
to  some  lowered  condition  of  resistance. 

Acute  Endocervicitis 

Acute  endocervicitis  is  usually  merely  a  part  of  a  generalized 
infection  of  the  genital  canal,  such  as  that  caused  by  gonorrhoea  or 
puerperal  sepsis.  The  cervical  discharge  is  mucopurulent,  or  in  the 
most  severe  cases  frankly  purulent  because  the  secretion  from  the 
cervical  glands  is  inhibited.  The  internal  os  tends  to  bar  further 
ascending  infection ;  therefore,  whilst  acute  cervicitis  is  common, 
acute  endometritis  is,  fortunately,  relatively  uncommon. 

Treatment. — This  is  considered  in  the  sections  on  Acute  Endo- 
metritis (p.  1012)  and  Vaginitis  (p.  995),  of  which  it  forms  a  part. 

Chronic  Endocervicitis  and  Cervical  "  Erosion  " 

Acute  cervicitis  is  very  apt  to  become  chronic,  because  (1)  the 
tortuous  cervical  glands  harbour  organisms,  and  (2)  local  treatment 
is  difficult  of  application. 

A  cervical  erosion  is  the  outward  sign  of  the  changes  in  progress 
throughout  the  cervical  canal. 

Three  stages  of  chronic  cervicitis  may  be  distinguished  : 

Stage  1. — The  subepithelial  tissue  is  crowded  with  cells,  chiefly  of 
the  lymphocyte  type,  with  some  polymorphonuclear  leucocytes,  which 
latter  are  also  seen  in  the  gland  lumina.  The  cervical  epithelium  is 
irregular  and  partly  desquamated.  Around  the  external  os  is  the 
area  of  "  erosion."  Here  the  same  subepithelial  lymphocytosis  is  seen, 
while  the  superficial  layers  of  the  squamous  epithelium  have  desqua- 
mated.   The  surface,  therefore,  is  slightly  depressed  and  looks  raw  and 


CIIKONIG    KNDOCERVICITIS 


1009 


O 


Fig.  582. — Cervical  erosion,  granular  stage. 


granular  (granular  erosion)  (Fig.  582).  The  discharge  is  mucous  or 
mucopurulent. 

Stage  2. — Subepithelial  lymphocytosis  is  still  marked,  bul  other 
inflammatory  cells  are  appearing  (large  hyaline  cells  and  plasma  cells). 
The  cervical  glands 
are  hypertrophied 
and  tortuous,  and 
abnormally  mucini- 
ferous.  In  t  h  e 
eroded  area  the 
basal  layers  of  the 
epithelium  have  in- 
grown to  form  new 
glandular  crypts 
(glandular    erosion). 

In  some  cases  definite  papillae  of  the  hypercellular  subepithelial  tissue 
project  on  the  surface,  giving  it  a  raised  velvety  aspect  (papillary 
or  villous  erosion)  (Fig.  583).  The  discharge  is  clear  mucus,  and 
very  profuse. 

"Stage  3.  —  Sub- 
epithelial fibrosis 
occurs  with  disap- 
pearance of  elastic 
fibres  and  a  diminu- 
tion of  cellularity. 
The  epithelium  of 
the  cervical  canal 
thickens,  and  be- 
comes  almost 
squamous  in  places. 
In  the  eroded  area 
this  hypertrophy  is 
very  marked,  the 
epithelium  exhibit- 
ing interpapillary 
down-growths  like 
those  of  the  skin. 
(Fig.  584.)  The 
glandular  crypts  be- 
come occluded  by 
of    fibrous     tissue, 


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Fig.  583. — Cervical  erosion,  adenomatous  stage. 


the    thickened    epithelium  and   the    contraction 

and     numerous     slightly     raised     faintly     blue 

retention   cysts    present    on    the   surface   (ovules  of  Naboth).      The 

rest  of    the   "  erosion  area "   is  whitish  (cervical   leucoplakia).     The 

discharge    progressively  diminishes   as  the   glands  become  occluded, 

3  '» 


THE   UTERUS 


and  the  erosion  is  often  said  to  have  "  healed."  A  permanent 
change  is.  however,  now  established  in  the  cervical  tissues.  (See  under 
i  'arcinoma  of  the  Cervix,  p.  1019.) 

Clinical  features. — The  leading  symptom  of  chronic  cervi- 
citis is  leucorrhoea,  popularly  known  as  "  the  whites."  The  mucus 
escaping  from  the  cervix  is  transparent,  but  after  mixture  with  the 
creamy-coloured  vaginal  secretion  it  becomes  whitish  and  streaked.  It 
is  most  copious  in  the  earlier  stages  of  cervicitis,  and  gradually  lessens 
as  the  glands  become  occluded.  The  cervix  is  often  the  seat  of  old 
ununited  laceration.  It  is  doubtful  if  chronic  cervicitis  per  se  can  cause 
pain,  but  inasmuch  as  it  is  often  associated  with  endometritis,  retro- 
version or  prolapse, 
or  other  abnormal 
conditions  of  the 
genital  organs,  it  is 
often  associated  with 
pain. 

Differential 
diagnosis.  —  Cer- 
vical "  erosion  "  in 
its  earlier  phases  is 
'£■*  readily  distinguish- 
able from  carcinoma 
of  the  cervix,  but 
when  severe  and 
old  -  standing  may 
simulate  it  so  closely 
that  diagnosis  can 
only  be  made  by 
erosion  is   the    constant 


Fig.  584. — Cervical  erosion,  cystic  stage. 


microscopy.      Nor  is   this  surprising,   since 
precursor  of  carcinoma. 

In  general,  though  slight  oozing  may  follow  examination,  an  erosion 
never  bleeds  freely,  and  though  its  surface  may  be  irregular  and  rough, 
the  consistence  of  the  tissues  is  firm.  Carcinoma,  on  the  other  hand, 
always  bleeds  more  or  less  readily,  and  its  surface,  in  addition  to  being 
irregularly  excrescent,  is  friable.  In  all  cases  of  doubt  a  microscopical 
examination  should  be  made. 

Treatment. — Chronic  cervicitis  may  be  treated  either  by 
applications  or  by  operation. 

Applications. — Douches  are  customarily  prescribed  for  leucor- 
rhoea. Although  vaginal  irrigation  applies  chemicals  but  inefficiently 
to  the  cervical  canal,  it  is  of  use,  inasmuch  as  it  washes  away  the 
discharge,  benefits  the  surface  of  the  erosion,  and  allays  vaginitis.  In 
the  more  acute  stages  antiseptic  solutions  should  be  used,   such  as 


CHRONIC    ENDOCERVICITIS  wii 

iodine  (1  drachm  of  the  tincture  to  a  pint  of  water),  biniodide  of  mercury 
l    1,000),  or  lysol  (1  drachm  to  the  quart).     Later,  astringents  are 
employed,  such  aa  tannic  acid,  alum,  or  sulphate  of  zinc  (2  drachma  to 
the  quart). 

Soluble  vagina]  pessaries  containing  ichthyol  <>r  other  drugs  in  a 
glycerine  basis  are  a  more  potent  method  ol  making  applications  to 
the  cervical  surface. 

The  direct  application  of  antiseptics  auch  aa  carbolic  acid  or 
""  iodized  phenol"  (iodine  1.  phenol  •">)  on  a  swab  is  the  mosl  efficient 
method  of  direct  medication,  and  if  persisted  in  cures  a  certain  pro- 
portion of  cases.  It  is.  however,  a  lengthyj  troublesome,  and  uncertain 
means  of  treatment. 

Operations.  Scraping  the  diseased  cervical  mucosa  with  a  sharp 
scoop  is  the  most  rational  treatment.  No1  infrequently  it  is  also 
necessary  to  curette  the  corporeal  endometrium,  but  owing  to  the 
depth  to  which  the  cervical  glands  penetrate  the  tough  cervical  tissue, 
nothing  short  of  the  vigorous  application  of  a  strong,  sharp  scoop  will 
-uttiee  to  eradicate  them.  The  surface  of  the  erosion  is  similarly 
treated.  In  bad  cases  one  of  the  following  operations  may  be  per- 
formed. 

Trachelorrhaphy  is  indicated  where,  in  addition  to  the  cervicitis, 
the  cervix  is  badly  split.  The  lips  of  the  laceration  are  denuded  on 
their  inner  and  opposed  surfaces,  except  for  a  narrow  strip  in  the 
centre  of  each,  and  they  are  then  approximated  by  sutures,  so  that 
most  of  the  eroded  area  is  removed  and  the  laceration  repaired  at 
the  same  time.  The  cervical  endometrium  above  should  always  be 
scraped  as  well. 

The  operation  is  faulty,  in  that  a  strip  of  the  eroded  area  is  utilized 
to  form  the  lining  of  the  restored  part  of  the  cervical  canal. 

Tracheloplasty. — The  disadvantage  attaching  to  trachelorrhaphy 
is  avoided  in  tracheloplasty.  in  which  a  wedge  of  the  cervix  is  excised, 
including  the  whole  of  the  eroded  area.  The  edges  of  the  two  lips  thus 
formed  are  then  sutured  to  the  edges  of  the  cervical  canal  and  to  one 
another  on  either  side  of  this. 

Amputation  of  the  vaginal  cervix. — A  cuff  of  mucous  membrane 
covering  the  cervix  is  reflected,  the  cervix  amputated  circularly,  and 
the  edge  of  the  cuff  sutured  to  the  edge  of  the  cervical  canal.  It  is 
the  best  operation  for  persistent  and  severe  chronic  cervicitis,  and  is 
specially  indicated  where  the  vaginal  cervix  is  much  hypertrophied. 

TUBERCULOUS    CERVICITIS 

This  very  rare  condition  usually  coexists  with  corporeal  disease.  It 
presents  as  an  ulcerating  surface,  commonly  mistaken  for  carcinoma,  but  dis- 
tinguishable from  it  by  microscopy.     It  reepjires  hysterectomy. 


ioi2  THE   UTERUS 

ACUTE    ENDOMETRITIS 

Pathology. — Acute  infection  of  the  interior  of  the  uterus  is 
most  typically  seen  after  labour  and  abortion.  The  streptococcus  is 
usually  found  in  the  more  virulent  puerperal  infections,  but  the 
pneumococcus,  staphylococcus,  and  B.  coli  also  occur.  In  the  absence 
of  recent  pregnancy,  acute  endometritis  is  most  commonly  caused  by 
the  gonococcus,  but  it  may  also  arise  after  operations,  in  the  course  of 
the  extrusion  of  a  polypus,  or  as  a  consequence  of  a  breaking-down 
carcinoma. 

In  acute  streptococcal  endometritis  the  mucosa  is  necrotic,  either 
diphtheroid  or  foully  sloughing,  and  the  whole  uterine  wall  is  cedematous, 
and  often  presents  multiple  abscesses.  In  the  less  virulent  infections, 
such  as  the  gonococcal,  the  endometrium  is  frankly  suppurating,  the 
interglandular  stroma  is  packed  with  polynuclear  leucocytes,  and  much 
of  the  epithelium  has  desquamated. 

Clinical  features. — The  symptoms  of  puerperal  endometritis 
are  those  collectively  known  as  "  puerperal  fever,"  a  full  description 
of  which  will  be  found  in  obstetrical  textbooks.  Gonorrhceal  endo- 
metritis usually  supervenes  some  weeks  after  the  initiation  of 
the  infection.  There  is  much  pain  in  the  lower  abdomen  and  the 
vagina,  and  the  uterus  on  examination  is  very  tender.  The  pulse 
and  temperature  are  raised.  The  menstrual  period  may  be  suppressed 
orjexcessive. 

Diagnosis. — The  symptoms  of  acute  gonorrhceal  endometritis 
closely  resemble  those  of  acute  gonococcal  salpingitis,  with  which, 
indeed,  the  acute  uterine  inflammation  is  often  associated. 

The  presence  of  a  definite  swelling  on  one  or  both  sides  of  the 
uterus,  coupled  with  lower  abdominal  rigidity  and  distension,  is  an 
indication  of  salpingitis.  In  the  absence  of  these  signs  it  may  be  in- 
ferred that  the  affection  is  limited  to  the  uterus. 

Treatment. — Acute  puerperal  or  postabortional  endometritis 
is  dealt  with  by  immediately  exploring  the  uterine  cavity,  removing 
all  gestational  fragments,  and  thoroughly  irrigating  with  a  strong 
antiseptic.  Antitoxic  serums  or  vaccines  may  be  tried.  The  removal 
of  the  uterus  is  a  very  fatal  proceeding  in  these  cases. 

In  non-puerperal  cases,  especially  if  gonorrhceal,  no  operation  is 
usually  indicated.  The  patient  must  be  kept  in  bed,  and  pain  alleviated 
by  fomentations  to  the  abdomen  and  the  administration  of  sedatives. 
The  vagina  should  be  frequently  douched  with  some  mild  antiseptic 
in  hot  solution,  and  the  bowels  kept  open  by  saline  aperients.  Opera- 
tive interference  is  to  be  avoided,  for  it  might  precipitate  extension 
to  the  tubes. 

Where  a  sloughing  tumour  is  the  cause,  it  must  be  removed  if 
possible. 


CORPOREAL    IMI. ANIMATION 


1013 


the  drain 
lands  readily 


CHRONIC    ENDOMETRITIS 

This  is  very  ap1   to  follow   acute  infection,   becaus< 
from  the  uterine  cavity  is  poor,  while  the  numerous 
harbour  organisms.     In  many  cases  of  so-called  "endometritis,"  Imw 
ever,  endocervicitis  is  alone  present,  the  internal  oe  Eorming  a  i 
barrier  to  infection. 

Pathology.    Two  stages  may  be  distinguished— (1)  the   hyper- 
trophic, (2)  the  atrophic. 

I.  In  the  earlier  stage  the  endometrium  is  swollen  and  the  inter- 
glandular  stroma 
crew ded  with  in- 
flammatory cells. 
At  first  those  are 
largely  polymor- 
phonuclear leuco- 
cytes, but  later 
many  lymphocytes, 
with  plasma  cells 
and  other  forms, 
appear.  The  glands 
are  elongated  and 
distended,  and 
their  lining  epithe- 
lium is  irregular  at 
first  and  later  hy- 
pertrophic. (Fig. 
585.)  The  mucosa 
is  hypersemic,  as  is 
the  whole  uterus. 
The  endometrial 
surface  may  be  ir- 
regular or  even 
polypoid  (polypoid 
endometritis). 

2.  Later  the  stroma  becomes  shrunken,  fibrous,  and  much  less 
cellular.  The  glands  atrophy  and  disappear,  or  here  and  there  are 
maintained  as  retention  cysts.  (Fig.  586.)  The  fibrosis  extends  more 
or  less  deeply  throughout  the  whole  thickness  of  the  uterine  wall, 
producing  the  condition  known  as  fibrotie  metritis  (see  p.  1016). 

Clinical  features.  —  The  physical  signs  of  the  associated 
chronic  endocervicitis  are  present  as  well  ;  in  addition,  the  body  of 
the  uterus  is  enlarged,  and  in  the  earlier  stages  is  tender  and  soft, 
whilst  later  on  it  becomes  hard  and  painless. 

The  menstrual  loss  is  excessive,  especially  in  cases  of  fibrotie  metritis. 


Fig.  585.- 


Chronic  endometritis,  hypertrophic 
stage. 

The  glands  are  very  large  and  irregular.  The  double  or 
treble  epithelial  contours  are  due  to  Cross-sections  of  infoldings 
of  the  gland  walls.     The  stroma  is  full  of  inflammatory  cells. 


IOI4 


THE    UTERUS 


Leucorrhoea  from  the  cervix  is  constant,  and  the  enlarged  corporeal 
glands  in  the  hypertrophic  stage  also  occasion  a  watery  disci  3 
specially  marked  just  after  the  "period."  The  latter  is  accompanied 
by  an  aching,  bearing-down  pain,  referred  to  the  lower  abdomen, 
sacral  region  and  vagina.  Dyspareunia  may  be  complained  of  when 
the  uterus  is  tender,  and  conception  is  unlikely. 

There  is  a  variety  of  the  disease  known  as  senile  endometritis.  In 
old  age  the  uterine  mucosa  atrophies,  nearly  all  the  glands  disappear, 
and  the  epithelium  becomes  flattened  and  often  practically  squamous. 
Owing  to  the  absence  of  glands,  the  discharge  from  such  a  uterus,  if 

infected,  is  puru- 
lent or  seropurulent 
in-trad  of  being 
mucous  as  usual, 
and  is  very  apt 
to  become  foul. 
Eventually  the  en- 
dometrium is  l  *  - 
placed  by  a  thin 
layer  of  red  granu- 
lation tissue  from 
which  occasional 
small  haemorrhages 
may   occur. 

Treatment. 
1.  Drugs  and 
appl  ications. — 
Ergot  should  be 
given  to  diminish 
the  hyperemia  of 
the  uterus  and  to 
check  the  excessive 
menstruation.  Applications  of  iodine,  iodized  phenol,  or  carbolic- 
acid  may  be  made  to  the  interior  of  the  uterus,  and  the  general  health 
should  be  improved  by  suitable  treatment.  Soluble  vaginal  pessaries 
or  tampons  soaked  in  glycerine  are  sometimes  used.  Their  rationale 
is  doubtful  as  far  as  the  corporeal  inflammation  is  concerned. 

Curettage.— Where  definite  infection  of  the  uterine  cavity  i« 
present,  the  most  rational  treatment  is  curettage  of  the  diseased 
mucosa,  the  coexistent  endocervicitis  being  treated  at  the  same 
time,  as  previously  described. 

Auvard's  self-retaining  vaginal  retractor  having  been  inserted,  the 
cervix  is  drawn  down  with  two  pairs  of  volsella  forceps,  and  the  direc- 
tion of  the  uterine  cavity  ascertained  with  the  sound.    Hegar's  graduated 


w3H 


Fig.  58G. — Chronic  endometritis,  atrophic  stage. 

The    stroma   is    fibrous,   and    the    glands    much    reduced   in 
size  ;  some  have  undergone  cystic  dilatation. 


CHRONIC    ENDOMETRITIS  "•>> 

uterine  dilators  up  to  No.  Ii'  are  now  passed,  the  cavity  is  again 
sounded,  in  case  the  wall  lias  been  perforated,  the  curette  inserted, 
and  the  mucous  membrane  erased   in  ships  from  above  downwards. 

The  cervical  canal    is    then    scraped  with    a    sharp   9] □   and  the 

erosion  suitably  treated  [set  under  Endocervicitis,  p.  1  < » 1 1). 

Where  very  marked  evidence  of  infection  is  present,  especially 
if  gonorrhoea!,  the  operation  may  be  concluded  by  swabbing  oul  the 
uterus  with  iodine  or  iodized  phenol. 

The  dangers  of  curettage  arc  perforation  of  the  uterus  either  by 
a  dilator  or  by  the  curette,  and  postoperative  sepsis. 

Other  methods  of  treatment — Curettage  may  tail,  or  only 
succeed  temporarily.  In  fibrotic  endometritis,  and  still  more  in  diffuse 
hbrotic  metritis  (p.  1016),  the  curette  removes  nothing,  and  docs  little 
good.     In  gonorrhceal  cases  the  infection  may  be  very  persistent. 

In  such  circumstances,  the  operation  may  be  repeated,  and  the 
uterus  swabbed  out  with  chloride  of  zinc  (30  gr.  to  an  ounce),  or  with 
pure  nitric  acid  applied  through  a  glass  tube,  but  these  measures  are 
not  without  risk.  To  the  same  end  superheated  steam  has  been  applied 
with  a  special  apparatus  (atmocausis). 

When  severe  menorrhagia  persists  in  spite  of  a  thorough  trial  of 
styptic  drugs  and  properly  performed  curettage,  and  particularly  when 
the  curette  scrapes  hard  and  rough  without  removing  any  appreciable 
amount  of  tissue,  diffuse  fibrotic  metritis  is  probably  present.  In  Buch 
cases  the  best  treatment  is  hysterectomy  (p.  1022). 

PYOMETRA 

Distension  of  the  uterus  with  pus  occurs  sometimes  in  senile  endo- 
metritis, the  cervix  being  stenosed  by  atrophy.  It  is  also  seen  in  the 
later  stages  of  cervical  carcinoma.  The  uterus  is  soft  and  enlarged, 
and,  viewed  from  the  abdominal  aspect,  presents  a  number  of  dilated 
capillaries  on  its  surface.  Fever  and  pain  may  be  present,  but  some 
cases  show  very  few  symptoms.  The  condition  is  only  discovered  on 
the  escape  of  thick  greenish  pus  when  the  sound  is  passed. 

Treatment. — Carcinoma,  if  present,  must  be  eradicated,  if 
possible.  In  senile  endometritis  vaginal  hysterectomy  is  the  best  pro- 
ceeding, but  curettage  and  strong  iodine  solution  may  first  be  tried. 

TUBERCULOUS   ENDOMETRITIS 

In  this  rare  affection  the  mucosa  is  greatly  thickened  by  diffuse 
cell  proliferation,  amidst  which  giant  cells  are  found.  The  condition 
is  sometimes  found  post  mortem  in  persons  dead  of  tubercle  elsewhere. 
Often  there  have  been  no  symptoms.  In  other  cases,  irregular  bleeding 
and  offensive  discharge  have  led  to  a  diagnosis  of  carcinoma.  Treat- 
ment consists  in  removal  of  the  uterus. 


ioi6  THE   UTERUS 

ENDOMETRIAL    HYPERTROPHY 

Hypertrophy  of  the  endometrium  may  follow  non-infective  chronic 
uterine  enlargement  and  hypervascularity,  particularly  that  caused  by 
myomas.  In  such  cases  the  mucous  membrane  exhibits  a  diffuse 
hypertrophy,  differing  from  that  of  endometritis  in  the  absence  of 
inflammatory  cells.  Cervicitis  and  cervical  erosion  are  not  present. 
A  watery  discharge  more  marked  after  the  menstrual  period  is  the 
•  haracteristic  symptom.  It  comes  from  the  enlarged  uterine  glands. 
Menorrhagia  is  also  present.  Removal  of  the  thickened  mucosa  by 
the  curette  is  indicated  if  no  tumour  of  the  uterus  exists.  "Where  a 
myoma  is  present,  either  myomectomy  or  hysterectomy  is  called  for. 
Curettage  of  a  myomatous  uterus  may  produce  degeneration  or  infec- 
tive necrosis  of  the  tumour,  and  in  any  circumstances  is  likely  to  fail. 

FIBROTIC    METRITIS     (UTERINE    FIBROSIS) 

Within  the  last  few  years  a  pathological  condition  of  the  uterine 
wall  has  been  distinguished,  characterized  by  diffuse  fibrous  over- 
growth and  corresponding  muscular  degeneration.  Its  causation  is 
not  known  in  all  cases,  but  the  most  marked  examples  are  secondary 
to  long-continued  endometritis.  In  others  it  is  possibly  the  ultimate 
outcome  of  subinvolution  after  labour  or  abortion,  whilst  in  a  third 
group  a  primary  cirrhosis  of  vascular  origin  appears  probable. 

Macroscopically,  the  uterus  is  usually  somewhat  enlarged  and  very 
hard,  and  from  its  cut  surface  a  number  of  thick-walled  and  inelastic 
vessels  project.  Microscopically,  diffuse  fibrosis  is  seen,  especially 
under  and  in  the  endometrium,  which  is  shrunken  and  hard,  and  in 
the  worst  cases  ecchymosed.  The  vessels  have  largely  lost  their  muscular 
tunic,  and  in  places  are  converted  into  sinus-like  channels  without 
definite  coats. 

Symptoms. — Profuse  and  intractable  menstrual  haemorrhage  from 
a  uterus  but  slightly  enlarged  and  not  deformed  is  the  characteristic 
symptom.  The  loss  may  become  almost  continuous,  and  the  patient 
intensely  anaemic. 

Diagnosis. — Absolute  diagnosis  is  impossible  until  the  uterine 
cavity  has  been  explored,  for  similar  profuse  losses  may  be  caused  by 
intra-uterine  polyps,  or  small  sessile  myomas  or  adeno-myomas.  In 
fibrosis  the  cavity  is  empty,  and  the  curette  scrapes  hard  and  rough 
on  the  sclerotic  surface.  A  characteristic  feature  is  the  inability  of 
ergot  or  other  styptic  drugs  to  control  the  haemorrhage,  owing  to  the 
degeneracy  of  the  uterine  musculature.  Many  cases  are  repeatedly 
and  uselessly  curetted  before  the  true  diagnosis  is  made. 

Treatment. — Hysterectomy  is  usually  necessary,  total  if  the 
cervix  is  unhealthy.  In  doubtful  cases  a  thorough  curetting  should 
first  be  tried.  * 


CERVICAL   CYSTS   AND   POLYPI  ""7 

In  young  women  an  alternal  ive  to  hysterectomy  is  "  ut  riculopla 
as  practised  by  Kelly  and  myself.    The  operation  consists  in  excising 
a   wedge-shaped   portion  <>f  tin'  whole  thickness  "I   the  uterine  wall, 
the  base  at   the  fundus  and  the  apex  at   the  interna]  os,  followed   by 
suture  of  the  two  moieties  to  one  anothei  bo  Eorm  a  miniature 

uterus  or  " utriculus."     There  is  a  risk,  however,  <>f  the  hsemo] 

returning,    which    Bhould    1 splained   to   the    patienl    before    the 

operation.     My  first    case  lias  had    tun  pregnancies  subsequently  t<> 
the  operation. 

NEW  GROWTHS    OF   THE    UTERUS 

CYSTS    OF   THE   CERVIX 

Cervical  cysts  are  always  inflammatory  in  origin,  and  only  i 
sionally  attain  the  size  of  a  walnut.    The  treatment  is  that  appropriate 
to  chronic  cervicitis.      When  large,   the  cyst  should   be    excised,  or 
the  vaginal  cervix  amputated. 

POLYPUS   OF   THE    CERVIX 

Pathology. — Four  varieties  of  cervical  polypus  are  found  : 

1.  The  adenomatous  polypus  is  a  pedunculated,  very  vascular,  in- 
flammatory excrescence  of  the  cervical  mucous  membrane.  It  is 
covered  with  a  short  columnar  epithelium,  and  presents  a  number 
of  racemose  glands  surrounded  by  a  cellular  stroma.  It  is  bright 
red  in  colour  and  is  never  larger  than  an  almond. 

2.  The  cystic  polypus  is  similarly  derived  and  constructed,  but  the 
glands  have  undergone  cystic  dilatation.  (Fig.  587.)  These  polypi, 
therefore,  are  much  larger,  often  lobulated,  and  are  pale  and  semi- 
translucent  in  appearance.  They  are  uncommon.  Both  this  and 
the  last   variety  are  collectively  known  as  "mucous  polyps." 

3.  The  myomatous  polypus  is  a  sessile  submucous  cervical  myoma 
which  gradually  becomes  pedunculated.  It  is  hard,  smooth,  and  pink. 
and  may  attain  a  large  size. 

4.  Sarcomatous  polypi  are,  fortunately,  rare,  and  such  as  have  been 
studied  have  been  of  the  small  round-celled  or  mixed-celled  variety. 
They  are  soft,  irregular  in  outline,  reddish-white  in  colour,  and  bleed 
profusely. 

Symptoms. — A  glandular  cervical  polypus  gives  rise  to  irregular 
losses  of  blood,  especially  after  manipulation  or  coitus,  from  the 
numerous  capillaries  contained  in  the  tumour.  The  symptoms  of 
cervicitis  are  invariably  coexistent. 

A  myomatous  polypus  of  the  cervix  may  occasion  no  symptoms, 
and  is  sometimes  discovered  accidentally,  for  since  the  corpus  is  unin- 
volved,  menorrhagia  is  not  associated  with  it,  as  with  myomas  higher 


ioi8 


THE   UTERUS 


^V^'-^r^^-i   -     ,  \- ;>,  ,       .its 


-^ 


up.     The  tumours,  when  large,  may  occasion  discomfort  by  their  size 
They  are  prone  to  necrosis,  owing  to  the  precariousness  of  a  blood 
supply  conveyed  through  a  narrow   pedicle,  and  may  then  cause  a 

very  foul  discharge 
-----         -•   ,  ,  with  constitutional 

symptoms.  I  biej 
may  separate  spon- 
taneously. 

Sarcomatous 
polypi  give  rise  to 
continued  bleeding, 
and  later  to  signs 
of  generalized 
metastasis. 

Treatment.- 
Glandular  and  cys- 
tic polyps  should 
be  evulsed  and  tin- 
cervical  canal  well 
scraped  with  a 
sharp  spoon.  My- 
omatous polyps 
may  also  be  evulsed 
if  small ;  otherwise 
they  should  be 
treated  by  the 
methods  described  at  p.  1042.  If  the  polyp  is  sarcomatous,  radical 
extirpation  of  the  uterus  is  indicated. 

CARCINOMA    OF 
.-.       v(;.  THE    CERVIX 

.  :W.  ':ii: :'/.?  Etiology — 

Carcinoma    of    the 
cervix  is  common- 
est    between     the 
,ges  of  40  and  50. 
It    is   very    rarely 
seen  before  30,  and 
occurs  with  lessen- 
ency  from 
old  age. 
The  disease 

Fig.  588.-Early  carcinomatous  ulcer   of  the        bears     a     remark- 
cervix.  a"^e  relationship  to 


Fig.  587. — Cystic  mucous  polyp. 

The  glands   are  dilated  and  full    of  retained   secretion, 
columnar  epithelium  lining  them  is  degenerate. 


The 


CERVICAL   CARCINOMA 


toig 


_. 


childbearing,  and  is  mosl  ancommoD  in  undoubted  virgins.  This 
ia  due  to  the  fad  thai  carcinoma  of  the  cervix  la  Buperimposed  on 
cervical  "  erosion." 

Pathology.  Two  Eorma  of  carcinoma  are  mel  with  in  the 
cervix,  the  squamous-celled  and  the  columnar-celled.  The  firs!  is  by 
Ear  the  more  common,  the  malignanl  epithelial  cella  being  derived  from 
the  interpapillary  down-growtha  of  the  hypertrophied  epithelium  thai 
covera  the  erosion.  (Figs.  588  and  589.)  It  ia  in  the  third 
of  an  erosion  that  carcinoma  is  most  likely  to  occur  [see  p.  1' (|  •'•'). 
The  columnar-celled 

growth     is    derived  „.;*  pfl  '..•"',;    , 

Erom   the  glandular  ^r**^L'~' 

elements     of      the 

cervix,    and    repre-  H 

sents    about    2   per  ^k 

cent,    of    the    total 
number  of  cases. 

Histologically. 
the  squamous-celled 
type  presents  a 
number  of  masses 
of  oval  cells  closely 
packed  in  alveolar 
spaces  between  the 
cervical  tissues. 
These  cells  usually 
show  no  tendency 
to  keratinize,  and 
cell  nests  are  un- 
common. (Fig.  589.) 

From  the  pri- 
mary growth  exten- 
sion occurs  both  by 

lymphatic  permeation  and  by  infiltration.  The  lymphatic  tract  first 
affected,  as  a  rule,  is  that  extending  outwards  below  the  uterine  artery 
towards  the  pelvic  wall,  from  which  it  ascends  to  communicate  with  the 
lymphatics  and  glands  between  the  external  iliac  artery  and  vein. 

These  glands,  together  with  others  irregularly  scattered  in  the 
broad  ligament,  arc  therefore,  the  earliest  affected  by  metastatic 
growth.  It  is,  however,  remarkable  that  in  more  than  half  of  the 
patients  dying  of  the  disease  no  glandular  involvement  is  found  on 
autopsy  (Leitch).  In  this  respect,  therefore,  carcinoma  of  the  cervix 
is  much  less  malignant  than  carcinoma  in  many  other  parts  of  the 
body.    Glandular  enlargement,  when  found,  is  not  necessarily  carcino- 


Fig.  589. 


-Squamous-celled  carcinoma  of  the 
cervix. 


The  cells  lie  in  masses   closely  packed.      There  is  no 
keratinizatiou  or  cell-nest  formation. 


io2o  THE   UTERUS 

matous,  for  the  invasion  of  a  lymphatic  gland  by  carcinoma  is  preceded 
by  inflammatory  enlargement.1 

Metastatic  growths  other  than  those  in  lymphatic  glands  are  rare. 

Infiltrative  growth,  as  opposed  to  permeation  of  trunk  lymphatics, 
occurs  in  several  directions.  Anteriorly,  the  vaginal  vault  and  the 
bladder  become  in  time  involved.  Posteriorly,  extension  occurs  along 
the  utero-sacral  folds,  the  posterior  vaginal  vault,  and  the  recto-vaginal 
septum.     Laterally,  the  carcinoma  spreads  into  the   broad  ligament, 


Fig.  590. 


V 


-Carcinoma  of  cervix,  fungating  type.     Removed  by  the 
radical  abdominal  operation. 


at  first  displacing  the  ureter  outwards  and  subsequently  involving  it. 
Downwards,  the  growth  involves  the  vagina. 

The  disease,  even  in  the  latest  stages,  practically  never  extends 
above  the  internal  os.  In  advanced  cases  chronic  salpingitis  is  usually 
found,  due  to  ascending  infection.    Pyornetra  is  not  uncommon. 

Symptoms. — The  earliest  symptom  in  most  cases  is  haemorrhage, 
at  first  slight  or  intermittent,  and  provoked  by  coitus,  examination, 
or  douching,  but  later  continuous,  and  sometimes  very  free.  Dis- 
charge other  than  blood  is  then  noticed  ;  it  is  watery  in  character, 
and  usually  peculiarly  offensive.  Occasionally  it  may  be  the  first 
1  See  the  author's  Hunterian  Lectures,  R.C.S.,  1900. 


CERVICAL   C  \KCl\n\l A 

symptom.  Pain  usually  supervenes  later,  Le  oi  .1  continuous  gnawing 
type,  and  is  referred  bo  the  lower  pari  <>t  the  back  and  thighs. 

Where  the  haemorrhage  is  severe,  greal  anaemia  follows,  but,  apari 
from  this,  most  patients  present  more  or  less  cachexia,  Occasionally, 
however,  the  face  is  fa1  and  cuddy,  almosl  to  the  close.  In  th<  later 
stages  of  the  disease,  fistulas  Eorm  between  the  vagina  and  the  bladder 
and  rectum.  Death  is  due  most  commonly  1"  suppression  of  urine, 
following  blockage  of  both  ureters  and  bilateral  hydronephrosis;  in 
other  cases,  to  exhaustion  from  loss  of  blood,  or  t<>  toxic  absorption. 

The  duration  of  the  disease,  from  the  earliest  symptoms  to  death, 


Fig.  591. — Carcinoma  of  cervix,  ulcerative  type.     Removed  by 
the  radical  abdominal  operation. 

in  patients  unoperated  upon,  is  on  an  average  one  year  and  nine  months 
(Leitch).    Its  progress  is  much  slower  in  old  women  than  in  the  young. 
There  are  four  common  clinical  types  of  the  disease  : 

(1)  In  the  /ungating  variety  the  growth  forms  a  large  irregular 
excrescence  which,  sprouting  from  the  cervix,  fills  the  vaginal  vault 
(" caulifloiver  excrescence").  The  bleeding  is  usually  profuse,  but  the 
tendency  to  infiltration  and  lymphatic  permeation  is  less  than  in  the 
other  varieties.     (Fig.  590.) 

(2)  The  ulcerative  form  presents  as  a  deep  excavation  with  rugged 
and  friable  sides,  occupying  the  position  of  the  cervical  canal.  In 
these  cases  the  discharge  is  particularly  foul.     (Fig.  591.) 

(3)  In  the  massive  infiltrative  type  the  vaginal  cervix  is  much 
enlarged  and  indurated.  Little  can  be  seen  on  inspection,  but  blood 
persistently  oozes  from  the  external  os. 


io22  THE    UTERUS 

(4)  In  the  senile  atrophic  variety  the  vaginal  cervix  has  disappeared, 
and  is  replaced  by  a  depression  at  the  top  of  the  vagina,  from  which 
blood  oozes.  No  mass  or  ulcer  may  be  felt,  and  the  real  condition  is 
easily  overlooked. 

Diagnosis. — When  the  disease  is  well  established,  the  freely 
bleeding  friable  mass,  fungating  or  excavated,  can  scarcely  be  mistaken. 
The  massive  infiltrative  form  is  more  difficult  to  diagnose.  The  size 
and  induration  of  the  cervix,  not  less  than  its  tendency  to  bleed,  should 
awaken  suspicion.  Allusion  has  already  been  made  to  the  slight 
physical  signs  of  the  senile  atrophic  form. 

A  quite  early  case  of  carcinoma  of  the  cervix  is  rarely  seen.  Such 
cases  present  either  a  small  reddish  nodule  or  an  irregular  ulcer,  difficult 
to  distinguish  from  the  "erosion"  on  which  the  growth  is  beginning. 

The  surface  of  an  erosion,  though  perhaps  irregular  and  hard,  is 
never  friable,  and  though  it  may  sometimes  be  made  to  bleed  by  rough 
handling,  yet  any  pronounced  tendency  to  haemorrhage  immediately 
suggests  carcinoma.  The  diagnosis  of  early  cervical  carcinoma  is  often 
impossible  without  the  aid  of  the  microscope.  Therefore,  all  suspicious 
cases  should  be  immediately  examined  under  an  anaesthetic  and  a  portion 
of  the  suspected  tissue  removed  for  investigation.  The  comparative 
rarity  with  which  patients  seek  advice  in  the  early  stages  of  the  disease 
is  due  to  their  ignorance  of  the  significance  of  irregular  uterine  haemor- 
rhage. The  popular  delusion  that  the  premenopausal  period  is  normally 
associated  with  excessive  or  continued  bleeding  cannot  be  too  strongly 
combated,  nor  the  idea  that  the  absence  of  pain  negatives  a  malady 
of  any  importance.  It  is,  further,  of  the  highest  necessity  that  practi- 
tioners should  insist  on  a  vaginal  examination  before  treating  any  case 
of  genital  haemorrhage. 

Treatment. — All  cases  in  the  operable  stage  should  be  prompt  ly 
dealt  with  by  surgical  measures.  The  disease  may  be  attacked  from 
the  vaginal  or  the  abdominal  route. 

Vaginal  hysterectomy.  Standard  of  oper ability. — Simple  vaginal 
hysterectomy  is  only  applicable  when  the  growth  is  limited  to  the  cervix, 
when  sufficient  of  the  cervix  remains  to  get  a  hold  upon,  and  when 
the  uterus  is  sufficiently  movable  to  permit  of  its  being  pulled  well 
down  towards  the  vaginal  outlet.  Induration  of  the  broad  ligaments 
or  utero-sacral  folds,  or  extension  of  the  growth  on  to  the  vagina, 
bars  the  operation. 

Not  more  than  15  per  cent,  of  the  cases  are  seen  in  this  early  stage. 
The  operation. — The  growth  having  been  scraped  and  cauterized, 
and  the  limit  of  the  bladder  on  the  vaginal  vault  ascertained,  the 
mucous  membrane  covering  the  cervix  is  circumcised  at  its  junction 
with  that  of  the  vault.  The  bladder  is  then  separated  from  the  supra- 
vaginal cervix  by  scissors  and  swab  pressure  until  the  peritoneum  at 


HYSTERECTOMY  1023 

the  bottom  of  the  utero-vesical  pouch  is  reached.  This  is  then  opened. 
The  cervix  being  now  pulled  forwards,  the  utero-rectal  pouch  is  opened 
behind  it.  The  uterus  is  thru  pulled  down  and,  the  pulsations  of  the 
uterine  artery  baying  been  denned,  the  base  of  either  broad  ligament 
is  transfixed  above  the  vessel,  ligatured  and  divided.  The  uterus,  now 
much  more  mobile,  is  pulled  farther  down,  and  the  upper  part  of  the 
broad  ligament  with  the  ovary,  ovarico-pelvic  ligament,  tube  and  round 
ligament  on  either  side  is  included  in  a  couple  of  ligatures  and  divided. 
The*  vaginal  vault  is  partly  closed,  and  the  aperture  remaining  into 
the  peritoneal  cavity  lightly  plugged  with  gauze. 

When  access  to  the  upper  part  of  the  broad  ligaments  is  difficult, 
it  may  be  facilitated  by  anteflexing  the  uterine  body.    Sometimes 
better  simply  to  clamp  the  broad  ligaments  in  sections  before  dividing 
them,  and  to  apply  the  ligatures  afterwards. 

Advantages  and  disadvantages. — The  advantages  of  vaginal  hysterec- 
tomy are  its  ease  in  most  cases,  and  its  low  mortality  (about  6  per  cent.). 
But  not  more  than  15  per  cent,  of  the  cases  are  suitable,  and  of  these 
a  very  large  proportion  suffer  from  recurrence  within  a  year. 

Radical  hystero  -  vaginectomy  by  paravaginal  section. 
Standard  of  operability. — Access  to  the  pelvis  from  below  can  be  much 
facilitated  by  performing  paravaginal  section.  This  consists  in  making 
an  incision  along  the  junction  of  the  left  lateral  and  posterior  vaginal 
walls,  which,  dividing  the  skin  of  the  perineum  on  the  left  side,  sweeps 
round  the  rectum  towards  the  coccyx.  The  anterior  fibres  of  the  left 
levator  ani  are  severed  and  a  large  gap  is  effected,  through  which  a 
much  more  extensive  operation  is  possible. 

It  is  better  in  carcinoma  of  the  cervix  to  remove  the  whole  vagina 
with  the  uterus,  and  in  this  case  it  is  first  separated  from  the  skin 
and  its  end  sewn  up  so  as  to  exclude  the  disease  from  the  area  of  the 
operation.  It  is  then  dissected  free  of  the  bladder  in  front,  the  rectum 
behind,  and  the  cellular  tissue  laterally,  before  the  paravaginal  section 
is  performed. 

The  remaining  steps  are  similar  to  those  of  vaginal  hysterectomy, 
except  that  the  ureters  are  clearly  defined  and  pushed  aside,  so  that 
the  bases  of  the  broad  ligaments  may  be  ligatured  and  divided  far 
out  towards  the  pelvic  side  wall. 

Advantages  and  disadvantages.  —  By  paravaginal  section  about 
40  per  cent,  of  the  cases  are  operable.  Infiltration  of  the  vaginal 
vault  or  moderate  extension  into  the  broad  ligaments  or  utero-sacral 
folds  does  not  contra-indicate  the  operation,  but  extension  to  the 
bladder  or  rectum  or  massive  infiltration  around  the  ureter  renders 
it  impossible.  It  has  the  disadvantage  that  it  is  impossible  to  examine 
the  regional  glands  until  the  operation  has  been  practically  concluded, 
and  in  any  event  they  cannot  be  removed  by  this  route. 


io24  THE   UTERUS 

The  immediate  mortality  is  somewhat  lower  than  that  of  the 
radical  abdominal  operation,  but  the  convalescence  is  protracted,  the 
deep  hole  which  is  left  taking  weeks  to  granulate  up,  and  frequently 
sloughing  badly. 

Radical  abdominal  hystero-vaginectomy  (Wertheim's 
operation). — This  operation  aims  at  removing  the  uterus,  together 
with  the  upper  third  or  half  of  the  vagina,  in  such  a  way  that  the 
cervix  is  encapsuled  by  the  latter,  across  which  a  clamp  has  been 
placed  before  amputation.  Together  with  the  uterus  are  also  re- 
moved the  appendages,  broad  ligaments,  and  as  much  as  possible 
of  the  pelvic  cellular  tissue  and  regional  glands. 

Standard  of  operability. — So  long  as  the  growth  has  not  extensively 
involved  the  bladder  or  rectum,  or  absolutely  fixed  the  uterus  in  the 
pelvis,  its  removal  is  possible  by  this  method.  That  the  cervix  cannot 
be  pulled  down  is  of  no  moment,  if  it  can  be  pushed  up. 

It  is  often  impossible  to  be  certain  that  the  fixation  of  the 
uterus  is  due  to  carcinomatous  infiltration,  because  similar  physical 
signs  may  be  produced  by  the  chronic  salpingitis  which  commonly 
accompanies  advanced  growth.  In  estimating  the  degree  of  involve- 
ment of  the  bladder  or  ureter,  the  cystoscope  may  prove  useful.  In 
cases  of  doubt,  examination  under  an  anaesthetic  is  advisable,  and  if 
the  possibility  of  eradication  is  still  undecided  the  abdomen  should 
be  opened  and  the  condition  explored  from  above. 

By  Wertheim's  method  between  60  and  75  per  cent,  of  all  the 
cases  seen  are  operable,  according  to  the  views  of  the  individual  surgeon. 

The  operation. — The  growth,  if  foul  or  fungating,  is  first  thoroughly 
scraped  and  cauterized.  The  abdomen  is  then  opened,  either  imme- 
diately or  a  couple  of  weeks  later,  and  the  ovarico-pelvic  and  round 
ligaments  on  either  side  are  ligatured  and  divided  at  the  pelvic  brim. 
The  peritoneum  is  now  incised  across  the  front  of  the  uterus  at  the 
limit  of  its  loose  attachment,  and  by  swab  pressure,  aided  by  cautious 
snips,  the  bladder  is  pushed  off  the  supravaginal  cervix  and  the  upper 
inch  of  the  anterior  vaginal  Wall. 

The  ureter  of  one  side  is  now  felt  for  as  it  runs  in  close  attachment 
to  the  posterior  peritoneum  of  the  broad  ligament,  and  its  direction 
onwards  having  been  ascertained,  the  uterine  artery  is  sought  outside 
this  line,  is  lifted  by  pressure  forceps,  and  is  divided  and  ligatured  as 
far  outwards  as  possible.  By  tracing  the  distal  portion  of  this  vessel 
inwards  the  point  at  which  it  crosses  the  ureter  is  attained.  From 
this  point  onwards  the  ureter  is  separated  up  to  its  entry  into  the 
bladder.  Care  must  be  taken  not  to  injure  the  periureteral  sheath. 
The  other  ureter  is  then  similarly  treated. 

The  uterus  being  pulled  well  forwards,  the  peritoneum  at  the 
bottom  of  Douglas's  pouch  is  incised  and  the  rectum  separated  from 


WERTHKIM'S    OPERATION 


1025 


the  vagina.  The  utero-sacral  folds  are  then  divided,  the  ureter  being 
protected  by  the  fingers  during  the  process.  The  uterus  is  now  prin- 
cipally tethered  by  the  strong  lateral  cervico-pelvic  ligaments  that 
sweep  out  on  either  side  under  the  ureters  like  a  pair  of  buttresses. 
The  ureters  being  held  out  of  the  way,  these  ligaments  are  clamped 
by  angular  forceps  and  divided.  The  uterus  riding  up,  the  bladder  is 
still  further  separated  from  the  vagina  until  the  latter  can  be  clamped 
well  below  the  limit  of  the  growth.  For  this  purpose  the  Berkeley - 
Bonney  vaginal  clamp  (Fig.  592)  will  be  found  the  most  convenient. 
The  vagina  is  divided  below  the  clamp  either  with  the  cautery  knife 
or  with  a  scalpel.  All  bleeding-points  and  previously-clamped  tissues 
are  ligatured,  and  the  operator  then  proceeds  to  ablate  such  of 
the  parametric  and  paravaginal  tissue  as  has  escaped  removal  with 
the  uterus.  The  most  important  part  of  this  is  a  sheet  of  tissue 
against  the  side  wall  of  the  pelvis  at  the  upper  border  of  which  runs 


LFig.  592. — Berkeley-Bonney  vaginal  clamp. 


the  obliterated  hypogastric  artery.  When  this  sheet  is  removed  the 
obturator  fossa  and  the  glands  there  are  exposed.  The  latter  should 
be  removed.  The  glands  along  the  iliac  arteries  are  then  stripped 
off,  whether  enlarged  or  not,  and  all  bleeding  is  finally  arrested. 
The  vagina  is  left  open  for  drainage,  and  the  operation  completed 
by  sewing  the  anterior  peritoneal  flap  to  the  front  of  the  rectum  and 
back  of  the  pelvis.  Inability  to  empty  the  bladder  always  follows 
the  operation  for  a  few  weeks,  but  never  persists. 

Advantages  and  disadvantages. — The  surgeon  can  inspect  the  con- 
dition from  above,  and  proceed  no  further  if  he  finds  the  operation 
impracticable ;  he  can  excise  the  whole  adjacent  lymphatic  tract 
with  the  primary  growth  ;  by  removing  the  growth  encapsuled  in  the 
upper  part  of  the  vagina  he  minimizes  operative  cancer  infection  ; 
the  possibility  of  removal  is  greater,  and  the  number  of  patients  alive 
five  years  afterwards  is  higher  than  by  any  other  method. 

Against  these  advantages  may  be  set  the  high  primary  mortality 

of  the  operation — about  18  per  cent,  for  all  cases,  and  the  troublesome 

complications,  such  as  ureteral,  vesical,  or  rectal  fistula?,  that  sometimes 

follow   it.      In   estimating   the   mortality,    however,    the    enormously 

3  // 


1026 


THE   UTERUS 


increased  operability  rate,  as  compared  with  vaginal  hysterectomy, 
must  be  taken  into  account.  Comyns  Berkeley,  in  an  exhaustive 
paper,  has  shown  that  if  the  cases  be  classified  according  to  the  stage 
of  the  disease  at  the  time  of  operation,  the  mortality  figures  are — 
early,  6'3  per  cent.  ;  advanced,  23T  per  cent.  The  mortality  of  the 
operation,  therefore,  as  applied  to  early  cases,  i.e.  those  which  might 
have  been  dealt  with  by  vaginal  hysterectomy,  is  about  the  same 
as  that  of  the  latter  operation. 

The  difficulties  of  the  procedure  increase  greatly  in  advanced  cases, 
and  are  especially  formidable  in  very  stout  women.  Moreover,  the 
hospital  patients  in  whom  the  disease  is  most  commonly  met  are  from 


Fig.  593. — Fungating  type  of  carcinoma  of  the  body  of  the  uterus. 


the  surgical  standpoint  a  most  unsatisfactory  class,  most  of  them 
being  enfeebled  and  prematurely  aged  by  a  life  of  hardship  and  want. 
In  a  large  proportion  the  heart  is  fatty  or  the  kidneys  are  degenerate. 

The  ultimate  results  of  the  operation  must  at  present  be  estimated 
from  Continental  figures,  for  it  has  not  been  practised  sufficiently  long 
in  Great  Britain.  According  to  Wertheim,  nearly  60  per  cent,  of  those 
operated  upon  by  him  were  alive  five  years  afterwards.  Allowing  for 
a  wide  margin  on  results  so  remarkable  as  these,  British  surgeons  would 
be  satisfied  with  20  per  cent,  of  cures,  which  would  still  be  an  enormous 
advance  on  the  results  of  vaginal  hysterectomy. 

The  operation  must  not,  however,  be  judged  solely  by  the  permanent 
cures  effected,  for,  remembering  that  these  patients,  when  they  first 
seek  advice,  have,  on  an  average,  less  than  eighteen  unhappy  months 


CORPOREAL    CARCINOMA 


1027 


bo  live  if  the  disease  be  left  to  run  its  course,  the  gain  of  even  a  yeai 

of  health  and  hope  is  a  great  boon. 

Treatment  of  inoperable  cases — Where  the  jmwth  is  irremov- 
able, considerable  benefit  sometimes  follows  a  thorough  scraping  and 
cauterisation,  or  the  application  of  pure  acetone  by  a  tubular  speculum 
especially  in  foul,  fungating  cases.  Frequent  douching  with  crude 
sanitas  (1  oz.  to  a  pint)  restrains  the  fetor.  To  allay  pain,  aspirin 
in  10-gr.  doses  should  at  first  be  tried  ;  later,  phenacetin  is  useful. 
Morphia  should  be 

reserved    until    the  :t\^  -**^l..- 

latest     possible 
period. 


CARCINOMA    OF 
THE  BODY  OF 
THE  UTERUS 
Etiology 

This  disease  is  rare 
in  women  under  45. 
Its  maximum  inci- 
dence occurs  be- 
tween the  years 
from  50  to  60 — i.e. 
during  or  soon  after 
the  menopause — 
after  which  it  is 
met  with  in  les- 
sening frequency. 
It  is  much  less 
common  than  car- 
cinoma of  the  cer- 


Fig.  594. 


*V* 


-Columnar-celled  tubular  carcinoma 
the  body  of  the  uterus. 

The   tubules   are   irregular,  and    in   many  the   epithelium  is 
several  cells  thick. 


Of 


vix,    and  contrasts 

markedly  with  it  in  that  it  has  no  relation  to  marriage  and  childbearing. 
Pathology. — There  are  two  macroscopic  forms — the  fungating 
and  the  ulcerative.  In  the  first,  the  organ  is  enlarged  and  its  cavity  is 
filled  by  a  soft  pulpy  growth  sprouting  from  the  wall  (Fig.  593) ;  in 
the  second,  the  uterus  may  be  quite  small,  though  its  interior  is 
excavated  by  a  diffuse  ulceration,  the  surface  of  which  is  irregular 
and  friable.  Microscopically  the  neoplasm  is  most  often  a  columnar- 
celled  adeno-carcinoma  (Fig.  594),  but  in  senile  patients,  in  whom 
the  corporeal  epithelium  has  undergone  degenerative  flattening,  a 
keratinizing  squamous  -  celled  growth  may  occur.  Lymphatic  per- 
meation follows  the  course  of  the  ovarian  vessels,  and  primarily 
reaches  the  lumbar  and  aortic  glands.         <    ' 


io28  THE   UTERUS 

Symptoms. — Persistent  haemorrhage  and  watery  discharge  are 
first  noticed,  but  pain  is  often  an  early  symptom.  Fetor  occurs  rela- 
tively later  than  in  cervical  carcinoma.  On  examination  the  uterus 
may  be  found  moderately  enlarged  and  soft,  whilst  in  many  cases  the 
cervix  is  so  patulous  that  the  finger  passed  through  it  detects  the 
soft  growth  above.  In  other  cases,  however,  the  diagnosis  can  only 
be  established  after  dilatation  of  the  canal,  digital  exploration,  and 
removal  of  a  portion  of  tissue  for  microscopical  examination. 

Later,  diffuse  peritoneal  and  omental  metastasis  occurs,  or  the 
patient  succumbs  to  massive  growth  in  the  lumbar  glands  or  multiple 
nodules  in  the  liver  or  lungs.  In  either  case,  irregular  nodules  and 
lumps  will  be  felt  through  the  abdominal  wall. 

Diagnosis. — Corporeal  carcinoma  is  the  commonest  cause  of 
post-menopausal  bleeding.  Senile  endometritis  sometimes  gives  rise 
to  slight  irregular  haemorrhages,  but  the  discharge  is  principally  pus. 
It  is,  however,  to  be  remembered  that  this  form  of  endometritis  is  the 
common  precursor  of  carcinoma  of  the  corpus.  Before  the  menopause 
patients  are  apt  to  attribute  the  symptoms  to  that  event ;  the  fatal 
results  of  this  error  have  already  been  mentioned  (see  p.  1022).  The 
diagnosis  may  be  obscured  by  the  presence  of  a  uterine  myoma,  but 
continuous  loss  is  not  characteristic  of  these  tumours.  All  cases  of  per- 
sistent haemorrhage  at  or  about  the  menopause  should  be  immediately 
investigated,  the  uterus  being  explored  under  an  anaesthetic  if  necessary. 

Treatment. — If  there  is  no  evidence  of  metastatic  growth 
the  entire  uterus  with  both  appendages  should  be  immediately  re- 
moved. This  is  best  accomplished  through  an  abdominal  incision,  but 
in  very  stout  women,  with  a  uterus  scarcely  or  not  at  all  enlarged, 
the  vaginal  route  may  be  chosen. 

The  after-results  of  hysterectomy  for  corporeal  are  far  better  than 
those  for  cervical  carcinoma. 

For  inoperable  cases  the  treatment  is  similar  to  that  for  inoperable 
carcinoma  of  the  cervix  (p.  1027). 

CHORION-EPITHELIOMA 

This  rare  and  interesting  growth  is  derived  from  the  foetal  tropho- 
blast.  It  usually  follows  abortion  or  labour  after  an  interval  of  but 
one  or  two  months,  but  occasionally  does  not  declare  itself  for  a  much 
longer  period.  It  is  peculiarly  associated  with  vesicular  moles,  and  all 
gradations  between  that  condition  and  pure  chorion-epithelioma  have 
been  found.  Though  usually  primary  in  the  uterus,  it  has  originated 
in  the  tube  after  tubal  gestation.  A  number  of  cases  are  also  on  record 
of  primary  vaginal  growth,  elements  of  the  trophoblast  having  migrated 
there  from  the  gestation  site  and  initiated  the  tumour.  Its  occurrence 
in  teratomas  will  be  referred  to  later  (p.  1074). 


CIIORION-KPITHKLIOMA  1029 

Pathology.  The  tumour  has  a  characteristic  deep  Mood  colour. 
Microscopically  it  presenta  three  types  of  cell  (1)  closely  set  hyaline 
mononucleate (1  cells  identical  with  the  Langhan8  cells  of  the  norma] 
chorionic  villus;  (•_')  larger  cells  of  the  Bame  type  laden  with  grannies; 
and  (3)  large  multinucleated  masses  of  protoplasm  (syncytia)  similar 
to  those  seen  on  the  periphery  of  the  "villus  of  art  early  gestation.  These 
cells  are  embedded  in  masses  of  fibrin  and  extensive  blood  extrav&sa- 


f  > 


r 


5 


~  '    £ 


*     y        * 


'  "    o  •'  0  •         " 

-  V 


«^ 


^^ 


Fig.  595. — Chorion-epithelioma,  showing  syncytia  and 
Langhans'  cells. 

tions.  The  microscopic  appearance  of  a  chorion-epithelioma  (Fig.  595)  is 
exactly  that  of  the  tissues  at  the  growing  margin  of  an  early  gestation. 
Modern  research  shows,  indeed,  that  in  the  process  of  the  embedding 
of  the  human  ovum  its  trophoblast  acts  practically  as  a  malignant 
tissue,  destroying  the  maternal  tissue  with  which  it  comes  in  contact. 
Normally,  this  infiltrative  power  is  arrested  after  the  first  few  weeks 
of  the  life  of  the  gestation  ;  occasionally,  however,  it  persists  and  leads 
to  malignant  growth.        k 

Metastasis  occurs  with  great  rapidity,  pulmonary  nodules  being 
particularly  common. 


1030 


THE   UTERUS 


Symptoms  and  diagnosis. — The  symptoms  are  haemorrhage, 
foul  discharge,  rapid  uterine  enlargement,  and  often  fever.  Inasmuch 
as  in  most  cases  abortion  or  labour  has  occurred  quite  recently,  the 
symptoms  simulate  those  of  retention  of  conception  products,  but  the 
true  diagnosis  should  be  suggested  by  the  enlargement  of  the  uterus, 
and  confirmed  by  a  microscopical  examination  of  the  uterine  contents. 


Fig.  596. — Large  interstititial  myoma  undergoing    cedematous 
degeneration. 


Treatment. — The  fullest  possible  extirpation  of  the  uterus, 
adnexa,  and  broad  ligaments,  with  the  upper  part  of  the  vagina,  is 
indicated.  Cases  of  spontaneous  disappearance  are  on  record,  but  as 
a  rule  the  growth  is  among  the  most  malignant  known. 

MYOMA   (FIBROIDS) 

Myomas  are  by  far  the  commonest  tumours  affecting  the  uterus. 
Rare  before  30,  after  that  age  they  are  met  with  in  increasing 
frequency  up  to  the  menopause.     It  is  very  doubtful  if  they  ever 


M  Y  O  M  A  :    M  ( )  R 1 1 1 1 )  A  NATO  M  Y 


[031 


originate  de  novo  after  this  epoch.  Their  cause  is  unknown,  but  is 
probably  related  in  some  way  to  sterility,  since  they  are  rare  in 
women  who  have  borne  children  early  in  life.  On  the  other  hand, 
their  presence  is  in  varying  degree  a  bar  to  conception. 

Morbid  anatomy. —Myomas  occur  in  three  main  sites — (1)  the 
uterine  body,  (2)  the  cervix,  and  (3)  the  broad  ligament.  They  are, 
however,  rarely  solitary,  so  that  the  various  forms  are  often  combined. 

1.  Corporeal  myomas. — It  is  customary  to  divide  these  myomas 
into  three  groups,  according  to 
whether  they  arise  in  the  midst 
of  the  musculature  of  the  uterine 
wall  (interstitial  myomas),  or  under 
its  mucosal  or  peritoneal  surfaces 
respectively  (submucous  and  sttb- 
peritoneal  myomas). 

An  interstitial  myoma  of  any 
size  bulges  both  inwards  and  out- 
wards. The  surrounding  uterine 
musculature  is  much  hypertro- 
phied,  so  that  the  organ,  quite 
apart  from  the  tumour,  is  much 
larger  than  normal.  The  cavity 
is  correspondingly  enlarged.  (Fig. 
596.) 

Submucous  myomas  bulge  on 
the  mucosal  surface  only.  The 
uterus  is  uniformly  enlarged  over 
them  and  its  cavity  is  much  in- 
creased. All  submucous  myomas 
are  at  first  sessile,  but  small  tu- 
mours often  become  polypoid. 

Subperitoneal  myomas  are 
also  at  first  sessile,  but  as  they  grow  they  tend  to  become  pedun- 
culated, so  that  a  very  large  tumour  is  frequently  attached  to  the 
uterus  by  quite  a  narrow  stalk.  The  uterus  is  not  enlarged  by  a  sub- 
peritoneal myoma,  but,  inasmuch  as  it  may  form  the  peduncle  of  a 
large  tumour,  its  vascularity  may  be  much  increased.     (Fig.  597.) 

2.  Cervical  myomas. — About  6  per  cent,  of  all  uterine  myomas 
grow  in  the  cervix.  These  tumours,  when  large  and  growing  inter- 
stitially  or  under  the  mucous  membrane,  cause  a  very  characteristic 
elevation  of  the  uterine  body  on  the  top  of  them.  (Fig.  598.)  The 
cervical  canal  is  immensely  elongated,  and  the  broad  ligaments  and 
bladder  are  undermined  and  stretched.  A  cervical  myoma  develop- 
ing on  the  front  of  the  cervix  (Fig.  599)  burrows  under  the  bladder  and 


Fig.  597. — Large  subperitoneal  pe- 
dunculated myoma,  growing  from 
the  posterior  wall  of  the  uterus. 


1032 


THE   UTERUS 


raises  it  out  of  the  pelvis ;  while  one  growing  from  its  back  (Fig.  600) 
may  undermine  the  peritoneum  at  the  bottom  of  Douglas's  pouch  and 

gradually     obliterate 

the  pouch  altogether. 
Cervical  myomas  grow- 
ing laterally  invade  the 
broad  ligament. 

3.  Broad-ligament 
myomas.  —  Tumours 
growing  laterally  from 
the  side  of  the  corpus 
or  cervix  expand  the 
broad  ligament.  These 
are  not  truly  of  the 
broad  ligament.  There 
are  several  tracts  of  un- 
striped  muscle  in  the 
mesometrium  from 
which  true  broad-liga- 
ment tumours  may 
originate.  (Fig.  601.) 
Thus,  myomas  of  the 
ovarico-uterine  and 
round  ligaments  occur. 
Others  are  found  occa- 
sionally springing  from 
the  muscle  fibres  that 
accompany  the  ovarian 
or  uterine  vessels. 
These  may  attain  a 
large  size,  and,  after 
distending  the  broad 
ligament  to  its  fullest 
kj  \  jfB?  capacity,  mount  up  into 

A  the  abdomen  by  strip- 

ping the  peritoneum  off 
its  posterior  and  lateral 
parietes.  The  pelvic 
colon  thereby  comes  to 
lie  sessile  on  the  mass, 
while  the  uterus  is  forced  to  the  opposite  side.  The  ureter  is  dis- 
placed inwards  with  the  peritoneum  except  in  the  rare  cases  of 
lateral  cervical  myomas  growing  very  low  down,  when  it  may  be 
raised  bodily  on  the  top   of  the  tumour. 


Fig.  598. — Typical  central  cervical  myoma. 
The  body  of  the  uterus  is  raised  on  the 
tumour. 


MYOMA  :     DKGKNKK  ATIONS 


io33 


Pathology. — A  uterine  myoma  in  its  earliest  stage  presents 
as  a  little  white  nodule  embedded  in  the  musculature.  Structurally,  it 
consists  of  densely  interlaced  unstriped  muscle  fibres  united  by  some 
connective  tissue.  (Fig.  602.)  It  contains  but  a  few  small  vessels, 
derived  from  the  adjacent  uterine  wall,  which  surrounds  the  tumour 
in  concentric  layers  and  forms  its  capsule. 

As  the  tumour  enlarges,  the  uterine  wall  around  it  hypertrophies, 
and  assumes  the  stratified  appearance  which  characterizes  the  muscu- 
lature of  the  pregnant  uterus. 

The  micro- 
scopical structure 
of  a  "  normal " 
myoma  is  identi- 
cal with  that  of 
the  muscular 
uterine  wall  itself, 
except  that  it 
does  not  contain 
considerable  ves- 
sels. Such  a  tu- 
mour takes  years 
to  attain  large 
size. 

Owing  prob- 
ably to  their  poor 
vascular  supply, 
myomas  are  par- 
ticularly prone  to 
degenerate ;  to 
this  more  than  to 
any  other  factor 
the  serious  symp- 
toms are  due. 
These  degenerations  must  be  considered  in  detail,  as  follows  : — 

Fibrotic  degeneration. — Characterized  by  increase  in  the  white 
fibrous  elements  of  the  tumour  and  disappearance  of  the  muscle 
tissue.  The  tumour  becomes  very  white  and  hard,  and  ceases  to  grow 
(fibro-myoma). 

Calcareous  degeneration. — Usually  a  senile  change.  The 
calcific  deposit  may  begin  centrally  or  peripherally.  The  tumour 
becomes  stony  hard  and,  of  course,  ceases  to  grow.  The  change  is 
most  apt  to  affect  pedunculated  subperitoneal  tumours  in  old  age,  and 
is  not  entirely  beneficent,  for  the  rough  surface  may  set  up  chronic 
peritonitis  around  it. 


Fig.  599. — Anterior  cervical  myoma  undermining 
the  peritoneum  of  the  utero-vesical  pouch.  A 
small  interstitial  tumour  is  also  present. 


i°34 


THE   UTERUS 


CEdematous   degeneration. — An  oedematous   swelling   affects 

the  interstitial  connective  tissue,  and  the  muscle  fibres  degenerate. 

The  tumour  becomes  pulpy  and  soft,  and  rapidly  enlarges  (see  Fig.  596). 
Myxomatoid  degeneration. — This  is  by  some  regarded  as  an 

advanced  stage  of  the  last  form.     Centrally,  the  tumour  is  converted 

into  a  yellow-green  jelly-like  substance.     True  mucin  is  not  present. 
Cystic  degeneration. — This,  again,  is  probably  a  further  stage 

of  softening.     Usually  only  one  cavity  is  present,  but  there  may  be 

several.  When  the  change  is  com- 
plete the  resemblance  to  an  ovarian 
cyst  is  considerable.     (Fig.  603.) 

All  the  last  three  forms  of  de- 
generation are  frequently  accom- 
panied by  chronic  peritonitis  in  the 
neighbourhood  of  the  tumour. 

Red  degeneration. — The  tu- 
mour here  exhibits  varying  tints, 
from  pink  up  to  mahogany-brown. 
The  change  is  considered  due  to 
thrombosis  of  the  vessels  supplying 
the  area,  and  is  therefore  analog- 
ous to  "  red  "  infarction.  In  some 
cases,  however,  the  coloration  is 
due  to  free  pigment,  probably 
hematogenous  ;  and  it  is  often  in- 
tensified on  exposure  to  the  air. 
The  degeneration  has  frequently 
been  recorded  in  connexion  with 
pregnancy,  and  is  characterized  by 
the  sudden  onset  of  pain  in  the 
tumour. 

Nsevoid  degeneration. — Oc- 
casionally a  myoma  becomes  very 
vascular,  a  number  of  thin-walled 
blood    spaces    developing    in    the 

tumour.    The  vessels  of  the  tumour  capsule  in  particular  become  very 

large,  and  the  whole  uterus  is  at  last  covered  with  large  varicosities. 

These  tumours  grow  very  fast,  and  enlarge  at  each  menstrual  period  ; 

on  auscultation  a  murmur  is  heard  over  them.    The  general  likeness  to 

pregnancy  is  often  considerable. 

"  Caseous  "  degeneration. — A  rare  change,  in  which  the  myoma 

undergoes  a  transformation  into  a  substance  resembling  adipocere. 

This  is  not  a  true  caseation. 

Sarcomatous  degeneration. — About  2  per  cent,  of  all  myomas 


Fig.  600. — Posterior  cervical  my- 
oma. The  uterus  also  contains 
a  small  submucous  polypoid 
myoma. 


MYOMA 


1035 


are  said  to  undergo  sarcomatous  change.  Myo-sarcoma,  round-,  spindle-, 
and  mixed-celled  sarcoma,  angio-sarcoma,  and  endothelioma  are  all  on 
record.  The  prognosis  of  thrs<'  transformed  myomas  is  better  than 
that  of  primary  sarcomas. 

Carcinoma  of  a  myomatous  uterus. — There  is  a  considerable 


Fig.  601. — Broad-ligament   myoma,  with   the   uterus,    unenlarged, 
to  the  right. 

amount  of  evidence  showing  that  myomas  predispose  to  the  develop- 
ment of  corporeal  carcinoma,  but  cervical  carcinoma  complicating  a 
myomatous  uterus  is  very  rare.     (Fig.  604.) 

Symptoms. — The  symptoms  of  uterine  myomas  may  be  divided 
into  four  groups — (1)  menstrual  symptoms,  (2)  pressure  symptoms, 
(3)  degeneration  symptoms,  and  (4)  symptoms  due  to  certain  com- 
plications and  accidents. 


1036 


THE   UTERUS 


i 


k 


V'^ ^-.<.  ■ 


1.  Menstrual  symptoms.— Menorrhagia  is  the  most  constant 
symptom.      It  i3  due  partly  to  the  increased   size   of   the    menstrual 

area,  partly  to  the  aug- 
mented vascularity  of  the 

.  uterus,   and  partly  to  un- 

known   causes.       For    the 

-  \  menstrual    period     is     in- 

creased not  only  in  quan- 
tity and  duration,  but  often 

*»g.-  also    in    frequency,     and, 

further,    a    small    submu- 

?  .  /  cous  nodule  may  produce 
haemorrhage  far  in  excess 
of  that  caused  by  a  much 
larger  mass  in  exactly  the 
same  position  in  another 
patient.  The  menorrhagia 
usually  begins  insidiously 
and      steadily      increases. 


■/\^w 


Fig 


602. — Uterine      myoma,      consisting 
almost    entirely    of     unstriped    muscle     Patients  have  generally  so 
fibres  running  in  various  directions.  suffered     for     some    years 

before  seeking  advice. 
Submucous  myomas  produce  the  most  severe  loss,  while  the  sub- 
peritoneal variety  may  cause  no  alteration  in  the  periods,  the  uterus 


Fig.  603. — Broad-ligament  myoma  that  has  undergone 
cystic  degeneration.  The  uterus  is  pushed  to  the  left, 
and  contains  several  smaller  tumours. 


MYOMA:    SYMPTOMS 


i°37 


proper  not  being  enlarged.  Menorrhagia  with  a  large  subperitoneal 
myoma  suggests  the  coexistence  of  .1  small  submucous  nodule.  <  lervicaJ 
myomas  arc  however,  often  associated  with  very  severe  loss,  although 
they  do  not  involve  the  menstrua]  area  proper. 

Patients  thus  afflicted  become  very  ansemic,  and  eventually  develop 
cachexia  associated  with  breathlessness  and  cardiac  degeneration. 
Dysmenorrhcea  is  not  a  common  symptom.     When  presenl  it  is  <>f  the 


Fig.  604. — Carcinoma  of  the  body  of  a  myomatous  uterus. 

obstructive  varietv,  and  consists  in  violent  spasms  of  pain  associated 
with  the  passage  of  clots  from  the  uterus. 

2.  Pressure  symptoms. — These,  when  severe,  are  generally  due 
to  impaction  of  the  tumour  in  the  pelvis.  Cervical  myomas  are 
particularly  prone  to  this  complication.  A  myomatous  uterus,  like 
a  pregnant  one,  may  become  retroverted  and  incarcerated. 

The  bladder  is  usually  the  first  organ  to  exhibit  symptoms  of 
pressure,  generally  in  the  form  of  frequency  of  micturition  ;  retention 
is  less  common  and,  when  present,  implies  impaction. 

Pressure  on  the  ureter  is  much  rarer  than  might  be  supposed,  but 
in  cases  of  prolonged  impaction  these  conduits  are  found  dilated. 

The  bowel  is  less  frequently  occluded  by  pressure  than  by  kinking 
due  to  displacement  or  adhesions.  Partial  intestinal  obstruction  is  not 
uncommon,  but  acute  symptoms  are  comparatively  rare. 


io38  THE    UTERUS 

Very  large  tumours  may  press  upon  the  vena  cava  and  produce 
oedema  of  the  legs,  or  may  distend  the  abdomen  sufficiently  to  embarrass 
respiration. 

3.  Degeneration  symptoms.— One  feature  alone  is  common  to 
most  degenerated  myomas,  viz.,  tenderness  supplants  the  insensi- 
tiveness  of  the  "  normal  "  tumour.  If  the  degeneration  be  cedematous. 
myxomatous,  or  cystic,  the  tumour  rapidly  increases  in  size.  The 
sudden  onset  of  pain  characteristic  of  red  degeneration  has  already 
been  mentioned.  In  many  forms  of  degeneration  slight  fever  is 
manifested. 

The  supervention  of  carcinoma  in  the  body  of  a  myomatous  uterus 
is  characterized  by  the  haemorrhage  becoming  continuous  instead  of 
periodic. 

Sarcomatous  degeneration  is  accompanied  by  severe  haemorrhage, 
rapid  bossy  enlargement  of  the  tumour,  ascites,  and  emaciation. 

4.  Symptoms  due  to  complications  and  accidents — In- 
flammation of  a  myoma  is  usually  caused  by  infection  from  the  uterine 
cavity.  This  very  serious  complication  especially  follows  labour  and 
abortion,  and  presents  the  signs  of  acute  local  peritonitis,  which 
later  may  become  generalized.  An  infected  myoma  usually  undergoes 
necrosis,  and,  if  submucous,  may  slough  out. 

Salpingitis  is  a  common  complication,  and  produces  its  usual 
symptoms.  It  is,  as  a  rule,  of  the  chronic  type,  the  tubes  being 
thickened  or  distended  with  clear  fluid.  Occasionally,  owing  to  re- 
gurgitation of  menstrual  blood,  a  double  hematosalpinx  is  present, 
and  especially  with  cervical  myomas.  Pyosalpinx  is  less  frequent 
(see  p.  1048). 

Ovarian  cysts  so  frequently  complicate  uterine  myomas  that  no 
wise  diagnostician  would  often  pledge  himself  that  the  ovaries  were 
undoubtedly  sound.  Many  masses  thought  to  be  purely  myomatous 
are  found  at  operation  to  be  partly  ovarian,  and  vice  versa. 

Extrusion  of  a  myoma  is  commonest  with  a  polypoid  submucous 
tumour,  but  may  follow  injury  or  ulceration  of  the  capsule  of  a  sessile 
one,  and  is  then  a  septic  process  from  the  beginning.  Extrusion  pro- 
duces severe,  painful,  colicky,  uterine  contractions  and  free  haemor- 
rhage, accompanied,  if  the  tumour  be  infected  or  sloughing,  by  fever 
and  foul  discharge.     (Fig.  605.) 

Axial  rotation  of  a  pedunculated  subperitoneal  myoma  is  charac- 
terized by  sudden  violent  pain  recurring  at  intervals,  tenderness  and 
rapid  enlargement  of  the  tumour,  and  the  early  development  of  local 
peritonitis.  Occasionally  the  uterus  itself  partakes  in  the  torsion. 
Such  cases  present  severe  shock  and  profuse  external  bleeding. 

The  supervention  of  pregnancy  varies  in  its  results.  A  subperitoneal 
tumour  of  moderate  size  permits  a  normal  termination  of  gestation. 


MYOMA  :    PHYSICAL    SIGNS 


t  v 


f 


[nterstitial  tumours  Bhow  apparenl  rapid  gro'w  th,  largely  due  to  byper- 
trophy  of  the  pregnanl  uterus  round  them;  the  ae1  increase  in  bulk 
may  Buffice  to  produce  pelvic  impaction  or  greal  abdominal  distension. 

A  submucous  tumour  strongly  militates  against   pregnancy,  bu1  if 
this  occurs  aborl  ion  is  probable. 

A  cervical  myoma  ot  a  pedunculated  subperitoneal  mass  that  has 
gravitated  into  the  pelvis  will  obstrucl  labour,  and  sessile  Eundal 
tumours  oo1  infrequently,  by  their  weight,  retroflex  the  Bofl  pregnanl 
ut  1'i'iis  and 
cause  incarcer- 
ation. During 
the  lying-in 
period  a 
'■  fibroid  ?'  may 
be  extruded 
or  may  slough 
out ;  while  pu- 
erperal sepsis 
affecting  a 

myomatous    uterus    is    a        ^ 
grave  disaster. 

Physical  signs The 

physical  signs  of  a  myoma 
vary  with  its  position.  Its 
connexion  with  the  uterus 
is  usually  obvious,  but 
pedunculated  subperitoneal 
tumours  may  appear  to  be 
entirely  separate.  Submu- 
cous    tumours    enlarge    the 

organ  uniformly,  while  those  nearer  the  peritoneal  surface  stand 
out  as  bosses  or  knobs.  A  cervical  myoma,  if  interstitial,  pro- 
duces a  typical  expansion  of  the  cervix  like  that  of  the  later 
months  of  pregnancy ;  if  submucous,  its  lower  pole  may  be 
felt  through  the  external  os.  Anterior  and  posterior  cervical 
myomas  displace  the  cervix  backwards  or  forwards,  while  those  in 
the  broad  ligament  carry  the  uterus  bodily  upwards  and  towards  the 
opposite  side.  The  palpability  of  a  myomatous  uterus  from  the  abdomen 
depends  upon  the  size  and  position  of  the  tumour.  Except  in  broad- 
ligament  myomas,  the  swelling  is  usually  central.  Cervical  myomas, 
even  when  large,  may  not  be  apparent  from  above.  The  abdominal 
tumour  is  usually  dull  on  percussion,  but  that  produced  by  the  cervical 
variety  may  be  partly  resonant  because  the  intestines  are  lifted  on  the 
mass.    Auscultation  may  reveal  a  souffle,  especially  when  the  uterus  is 


Fig.  603. — Submucous  myoma  in 
process  of  extrusion. 


1040  THE    UTERUS 

very  vascular,  as  in  naovoid  degeneration.  The  sound  is  produced  in 
the  vascular  leashes  of  the  broad  ligament,  and  is  heard  to  one  side 
of  the  mass. 

Diagnosis. — If  the  tumour  is  obviously  connected  with  the 
uterus,  it  only  remains  to  distinguish  it  from  the  enlargements  due  to 
pregnancy,  malignant  disease,  pyometra,  congenital  hsematometra,  and 
uterine  fibrosis.  Confusion  with  pregnancy  can  only  arise  during  the 
early  months.  Although  the  fact  that  amenorrhcea  practically  never 
occurs  with  a  myoma  unless  pregnancy  coexists  is  generally  distinctive, 
immediate  diagnosis  may  be  obscured  by  a  false  menstrual  history,  or 
by  the  irregular  haemorrhages  so  often  associated  with  early  pregnancy. 

In  such  a  case,  unless  the  symptoms  are  urgent,  the  surgeon  may 
either  watch  the  rate  of  tumour  growth  for  a  month  or  two,  or  place 
the  patient  under  observation  to  ascertain  beyond  doubt  the  presence 
or  absence  of  the  menses. 

Carcinoma  of  the  corpus  may  produce  uterine  enlargement  compar- 
able with  that  due  to  a  small  submucous  myoma,  but  continuous  loss 
and  watery  discharge  replace  the  periodic  noodings.  A  sloughing  myoma 
during  extrusion  may  closely  simulate  malignant  disease,  but  on  palpa- 
tion is  firm  and  hard,  quite  unlike  the  friable,  almost  pulpy,  feel  of 
carcinoma.  It  is  to  be  remembered  that  carcinoma  corporis  and 
myomas  frequently  coexist,  and  that  the  latter  very  rarely  begin 
to  give  trouble  after  the  menopause. 

Pyometra  is  often  due  to  carcinoma,  but  in  cases  secondary  to  senile 
endometritis  a  small  sloughing  myoma  may  be  simulated.  There  is, 
however,  little  or  no  bleeding  in  such  cases,  and  the  passage  of  a  sound 
under  anaesthesia  decides  the  diagnosis. 

Congenital  hcematometra  could  only  simulate  a  myoma  affecting  one 
horn  of  a  double  uterus. 

The  enlargement  and  severe  periodic  haemorrhages  due  to  fbrolic 
metritis  cause  close  resemblance  to  a  small  submucous  myoma.  In 
this  and  the  previous  case  the  history  and  age  of  the  patient  may 
decide,  but  the  diagnosis  can  often  only  be  clinched  by  exploratory 
operation. 

If  a  uterine  connexion  of  the  tumour  cannot  be  ascertained,  absolute 
diagnosis  is  impossible.  A  myoma  may  then  be  mistaken  for  an 
ovarian  tumour,  or  for  the  mass  formed  by  an  old  haematocele, 
chronic  salpingitis,  or  cellulitis. 

Scanty  menstrual  loss,  fluctuation,  a  smooth  contour,  and  compara- 
tively rapid  growth  strongly  favour  a  diagnosis  of  ovarian  cyst.  The 
swellings  due  to  encysted  blood  or  inflammatory  products  are  usually 
distinguishable  by  their  history.  The  importance  of  passing  a  catheter 
in  any  case  of  a  doubtful  abdomino-pelvic  tumour  cannot  be  insisted 
upon  too  often. 


MYOMA  :   TREATMENT  ">M 

Prognosis.  Once  a  myomatous  uterus  has  begun  to  cause 
symptoms,  no  material  respite  can  be  expected  until  the  menop 
It  must  be  remembeied,  however,  that  myomas  postpone  this  even! 
by  several  years.  At  the  menopause  the  patient  will  be  relieved  "I  the 
blood  loss,  hut  symptoms  dependent  upon  the  bulk  "I  the  tumour, 
ii a  degeneral ions  and  accidents,  are  especially  liable  to  supervene  aboul 
this  time.  If  these  dangers  are  escaped,  the  tumour  gradually  shrinks, 
though  it  probably  never  entirely  disappears.  The  likelihood  of  car- 
cinoma developing  is  always  present.  Although  rarely  fatal  per  se,  a 
myoma  indirectly  shortens  life  by  the  progressive  deterioration  of 
health  which  the  excessive  blood-loss  produces.  In  particular,  cardiac 
degeneration  is  common.  A  myomatous  uterus  usually  leads  to 
chronic  invalidism,  but  occasionally  direct  ly  menaces  life  from  excessive 
bleeding,  obstruction  to  the  functions  of  vital  organs,  toxic  or  septic 
absorption,  or  the  supervention  of  malignant  growth. 

General  remarks  as  to  treatment. — A  small  myoma 
causing  no  symptoms  and  discovered  accidentally  should    be  let  alone. 

Where  symptoms  indicate  treatment,  two  methods  present  them- 
selves, medical  and  surgical. 

If  menstrual  haemorrhage  is  the  only  symptom,  ergot  and  other 
styptic  drugs  may  control  it.  The  adoption  of  non-operative  measures 
must  be  considered — (a)  where,  in  the  absence  of  urgent  symptoms,  the 
patient  expresses  strong  repugnance  to  operation;  (6)  where  the  meno- 
pause is  approaching,  and  moderate  haemorrhage  is  the  only  symptom  ; 
and  (c)  where  operation  is  undesirable  on  account  of  cardiac,  pulmonary, 
or  other  disease. 

If,  however,  the  bleeding  is  severe  or  the  patient's  social  position 
interferes  with  the  regime  imposed  by  medical  treatment,  operation 
should  be  advised.  Again,  if  the  climacteric  is  several  years  distant, 
medical  treatment  is  contra-indicated,  for,  apart  from  the  life  of  in- 
validism to  which  the  patient  is  condemned,  the  habitual  exhibition 
of  ergot  exercises  a  deleterious  effect  on  the  heart  and  vessels.  Symp- 
toms due  to  pressure  degeneration  or  any  of  the  accidental  occurrences 
to  which  these  tumours  are  liable  indicate  immediate  resort  to  surgery. 

Pregnancy  is  undesirable,  except  when  the  myoma  is  small  and 
subperitoneal ;  moreover,  conception  is  unlikely  and  dangerous  in  a 
myomatous  uterus  ;  therefore  removal  of  the  tumour  is  advisable,  even 
if  it  involve  hysterectomy  and  obligatory  sterility. 

Medical  treatment. — Ergot  is  the  most  satisfactory  drug 
for  controlling  the  menorrhagia.  The  liquid  extract  (20  to  30  minims 
three  times  daily),  combined  with  strychnine  and  a  dilute  acid  to 
exalt  its  effect,  should  be  administered  from  a  few  days  before  the 
onset  of  the  flow  to  its  end.  and  then  stopped.  Sometimes  it  gives 
rise  to  severe  uterine-contraction  pain,  and  may  be  refused  on  this 
3o 


io42  THE   UTERUS 

account.  Should  ergot  fail,  hydrastis  and  hamamelis  may  be  tried 
in  doses  of  15  and  30  minims  of  the  liquid  extract  and  tincture  respec- 
tively. The  hydrochloride  and  phthalate  of  cotarnin  (stypticine  and 
styptol)  may  also  give  satisfactory  results.  At  the  time  of  the  period 
the  patient  should  rest  in  bed  ;  after  it  is  over,  iron  in  some  readily 
absorbable  form  should  be  administered.  The  treatment  of  myomas 
by  various  forms  of  electricity  has  deservedly  fallen  into  disrepute. 

Surgical  treatment. — The  ideal  treatment  of  a  myoma 
would  at  first  sight  appear  to  be  the  removal  of  the  tumour  with  con- 
servation of  the  uterus.  Collected  statistics,  however,  show  that 
myomectomy  is  no  safer  an  operation  than  hysterectomy,  and  that  it 
sometimes  fails  to  cure  the  menorrhagia  because  (1)  in  many  cases  a 
much  hypertrophied  uterus  is  left  behind  ;  (2)  a  small  submucous 
tumour  may  be  overlooked  and  keep  up  the  excessive  loss  ;  and  (3)  in 
a  certain  number  of  cases  new  tumours  subsequently  develop.  At  this 
possible  cost  is  gained  the  dubious  privilege  of  continued  menstruation 
and  the  undoubted  advantage  of  possible  pregnancy,  although  not 
more  than  10  per  cent,  of  patients  on  whom  myomectomy  has  been 
performed  subsequently  conceive. 

Myomectomy,  then,  is  only  to  be  preferred  to  hysterectomy  (1) 
where  the  operation,  though  equally  efficacious,  is  associated  with  less 
risk,  as  in  small  solitary  submucous  tumours  causing  haemorrhage,  or 
subperitoneal  masses  causing  pressure  or  degeneration  symptoms ; 
(2)  where,  on  account  of  the  patient's  age  and  social  state,  the  possi- 
bility of  future  pregnancy  justifies  an  attempt  to  conserve  the  uterus, 
even  at  a  somewhat  increased  risk  ;  and  (3)  where  the  patient  strongly 
desires  the  attempted  conservation  of  the  uterus  after  the  possible 
increased  risk  has  been  explained  to  her. 

Abdominal  myomectomy. — If  the  tumour  is  pedunculated,  it 
may  be  removed  by  simple  ligature  of  the  pedicle  in  sections.  If  the 
tumour  is  sessile,  or  its  pedicle  too  massive,  it  should  be  enucleated  ; 
the  bleeding  from  the  capsule  is  controlled  by  under-running  with 
"  mattress  "  sutures,  and  the  peritoneum  closed  over  the  uterine  wound 
with  Lembert  stitches.  Interstitial  and  submucous  tumours,  unless 
small  and  solitary,  should  not  be  treated  by  abdominal  myomectomy. 
Small  broad-ligament  myomas  can  be  easily  shelled  out. 

Vaginal  myomectomy. — Small  polypoid  submucous  myomas  can 
easily  be  evulsed.  If  the  polyp  is  contained  entirely  within  the  uterine 
cavity  the  cervix  must  first  be  dilated.  Sessile  submucous  myomas,  if 
not  larger  than  a  bantam's  egg,  can  be  enucleated  and  removed  through 
the  cervix,  their  capsule  having  been  first  divided.  Occasionally  these 
tumours  will  not  enucleate  owing  to  capsular  adhesions,  and  adeno- 
myomas  are  never  enucleable.  Enormous  submucous  tumours  can 
be  removed  per  vaginam  piecemeal  ("  morcellement  ")  with  scissors. 


HYSTKRKCTOMY  1043 

Where  a  solitary  myoma  is  already  iix  process  of  extrusion,  and 
especially  if  it  is  Bloughing,  vaginal  myomectomy  should  always  be 
undertaken  id  preference  to  hysterectomy. 

Hysterectomy. — Most  gynaecological  surgeons  hold  thai  where  the 
vagina]  cervix  is  healthy  it  should  be  conserved.  A  few  prefer  the  total 
operation  Eor  all  cases,  on  the  ground  thai  the  cervical  stump  may,  if 
infected,  cause  troublesome  discharge,  or  may  develop  carcinoma  ;  but 
infection  is  an  avoidable  fault  of  technique,  and  cervical  carcinoma 
in  these  patients  is  unlikely  because  of  their  sterility.  The  conserva- 
tion of  the  cervix  maintains  the  integrity  of  the  vaginal  vault,  while 
the  subtotal  operation  is  always  easier  than  the  extirpation  of  the 
entire  uterus.  The  following  are  the  most  important  methods  of  per- 
forming hysterectomy  : — 

Subtotal  hysterectomy. — The  uterus  having  been  pulled  up  through 
a  median  incision,  a  pressure  forceps  is  clamped  on  the  tube  and 
ovarico-uterine  ligament  with  its  contained  ovarian  vessels  on  each 
side,  and  a  second  pair  is  applied  to  the  round  ligaments  about  an 
inch  from  the  uterus.  The  broad  ligaments  are  now  divided  between 
the  clamps  and  the  uterus  as  low7  down  as  the  level  of  the  internal  os. 
A  flap  of  peritoneum  on  the  front  of  the  uterus  is  then  reflected  from  the 
upper  limit  of  its  loose  attachment  downwards.  The  uterine  vessels 
are  now  in  view  as  they  run  up  either  side  of  the  uterus.  They  are 
clamped  by  pressure  forceps  just  above  the  point  where  they  leave 
the  parametrium  to  enter  the  uterus,  and  the  latter  is  amputated 
about  \  in.  above  this  line.  The  uterine  vessels  on  each  side  are  next 
secured  by  a  ligature  which,  transfixing  the  tissue  of  the  cervical  stump 
just  within  them,  is  carried  round  them  and  tied  on  their  outer  side. 
The  clamped  broad  ligament  on  each  side  is  transfixed  between  the 
forceps  holding  the  ovarico-uterine  ligament  and  tube  and  the  round 
ligament,  and  the  transfixing  ligature  divided  into  two  :  one  half  is 
used  to  secure  the  tube  and  ovarian  pedicle  with  its  contained  ovarian 
vessels  ;  and  the  other,  rethreaded  on  a  needle,  is  inserted  as  a  pucker- 
ing suture  along  the  edge  of  the  divided  broad  ligament  as  far  as  its 
junction  with  the  cervical  stump.  The  two  ends  of  this  thread  are 
then  made  to  encircle  the  round  ligament  and  are  tied  together. 

Any  oozing  from  the  cervical  stump  may  be  stopped  by  one  or 
two  mattress  sutures.  The  anterior  peritoneal  flap  is  then  united  to 
the  peritoneum  on  the  posterior  aspect  of  the  stump,  and  the  operation 
concluded  by  closing  the  abdominal  wound  in  three  layers. 

Total  hysterectomy. — The  steps  of  the  total  operation  are  similar  to 
those  just  described  up  to  the  point  at  which  the  anterior  peritoneal 
flap  is  turned  down.  After  this  the  bladder  is  gently  separated  by 
swab  pressure  from  the  supravaginal  cervix,  sufficiently  low7  to  expose 
freelv  the  anterior  vaginal  wall.     The  vagina  has  now  to  be  opened, 


IQ44  THE   UTERUS 

either  from  in  front  or  from  behind.  In  the  latter  case  the  step  is 
facilitated  by  cutting  down  upon  a  large  uterine  dilator  previously 
placed  in  the  vagina.  In  either  case,  both  walls  must  be  divided 
transversely  in  the  middle  line  for  about  an  inch.  The  fingers  can  now 
be  thrust  across  the  vagina  under  the  uterus,  and  the  mass  pulled  up. 
Each  uterine  artery  having  been  clamped  just  before  it  enters  the 
uterus,  the  lower  part  of  the  broad  ligament  and  the  lateral  vaginal 
vault  are  divided  and  the  organ  is  removed. 

The  ovarian  vessels  and  round  ligaments  are  secured  as  previously 
described.  The  uterine  arteries  are  ligatured  separately.  The  lateral 
vaginal  vessels  exposed  just  outside  the  lateral  angles  of  the  divided 
vagina  are  treated  by  mattress  suture. 

The  anterior  peritoneal  flap  is  now  united  to  the  edge  of  the  cut 
peritoneum  on  the  posterior  vaginal  wall,  but  the  latter  canal  is  not 
further  occluded,  as  it  is  important  in  these  cases  to  leave  a  channel 
open  in  case  the  ligatures  on  the  uterine  and  vaginal  vessels  become 
infected  from  the  vagina.  The  ureters  are  liable  to  damage  during 
total  hysterectomy  unless  their  course  is  clearly  defined  and  the  bladder 
wall  separated  from  the  upper  part  of  the  vagina. 

Hysterectomy  for  cervical  myomas. — The  technique  just  described  is 
not  proper  for  cervical  myomas.  In  such  cases  the  spreading  of  the 
broad  ligaments,  the  displacement  of  the  bladder,  and  the  fixity  of 
the  mass  render  the  ordinary  methods  of  securing  the  uterine  vessels  and 
amputating  the  uterus  impossible.  The  difficulty  in  these  cases  is  the 
control  of  bleeding  during  the  removal  of  tumour  and  uterus,  which, 
therefore,  must  be  accomplished  as  quickly  as  possible.  The  upper 
part  of  the  broad  ligaments  having  been  clamped  and  divided,  the 
loose  anterior  peritoneum  and  the  bladder  are  pushed  off  the  front  of 
the  expanded  supravaginal  cervix  as  low  as  possible.  The  expanded 
tissue  forming  the  tumour  capsule  is  now  divided  transversely  in  the 
mid-line  for  about  an  inch,  and  by  introducing  the  finger  the  plane 
of  cleavage  between  the  tumour  and  the  capsule  is  defined.  The 
incision  is  then  prolonged  to  either  side,  and  the  lower  pole  of  the 
tumour  enucleated  from  its  bed  and  pulled  up.  The  incision  is  now 
extended  around  the  uterus  on  each  side,  the  uterine  vessels  being 
clamped  en  passant.  Subtotal  hysterectomy  is  thus  effected,  the 
lower  part  of  the  capsule  of  the  tumour  (i.e.  the  expanded  supra- 
vaginal cervix)  being  left  behind.  This  is  trimmed  up,  or  entirely 
removed,  and  the  vessels  are  secured. 

Hysterectomy  for  broad-ligament  myomas. — After  clamping  and 
dividing  the  broad  ligament  with  its  contained  ovarian  vessels  and 
round  ligament,  which  are  stretched  over  the  tumour,  the  latter  is 
enucleated  as  far  as  it  will  easily  separate.  The  opposite  broad  liga- 
ment is  divided  in  the  classical  manner,  and  the  uterine  artery  on  that 


UTERINE   SARCOMA  1045 

side  having  been  secured,  the  body  of  the  uterus  is  amputated  toward* 
the  tumour,  the  uterine  vessels  on  thai  side  being  clamped  as  t  bey  come 
into  view  or  spun .  The  enucleation  <>f  the  tumour  Erom  its  Wed  m  t  lie 
base  of  the  broad  ligament  is  now  easily  effected,  and  the  whole  mi 
removed.  The  difficulty  in  these  cases  arises  bom  the  danger  of 
haemorrhage  Erom  the  uterine  vessels  <>n  the  tumour  side. 

During  the  removal  of  either  a  cervical  or  a  broad-ligamenl  myoma 
the  greatest  care  must  be  taken  to  avoid  injuring  the  ureters;  this  is 
best  done  by  working  inside  the  capsule  of  the  tumour  in  the  manner 
just  described. 

ADENO-MYOM  \ 

These  tumours,  the  " unencapsuled  fibroids"  of  the  older  writer-. 
have  only  recently  been  generally  recognized.  Macroscopically  they 
form  a  mass  in  the  uterine  wall  underneath  the  mucous  membrane, 
and  blending  with  it  :  this  may  be  limited  to  one  part,  or  may  extend 
right  round  the  cavity.  The  cut  surface  has  a  peculiar  honeycombed 
appearance,  shown  by  the  microscope  to  be  due  to  areas  of  tissue, 
exactly  resembling  the  structure  of  the  endometrium,  embedded 
amongst  the  interlacing  muscle  bundles  which  make  up  the  rest  of 
the  tumour.  The  etiology  is  unknown.  The  age-incidence  and  symp- 
toms are  indistinguishable  from  those  of  myomas.  The  treatment 
is  that  for  myomas,  from  which  they  can  only  be  diagnosed  after 
removal  of  the  uterus.     They  cannot  be  enucleated. 

SARCOMA 

Sarcoma  of  the  uterus  is  usually  met  with  as  a  degenerative  com- 
plication of  uterine  myomas,  but  it  may  occur  apart  from  those  tumours. 
Histologically  it  may  belong  to  the  round-,  spindle-,  or  mixed-celled 
types,  while  myo-sarcoma,  endothelioma,  and  giant-celled  sarcoma  are 
occasionally  encountered. 

Symptoms. — A  sarcoma  may  appear  as  a  rapidly  growing  intra- 
uterine polyp,  winch  soon  recurs  after  removal ;  at  other  times  it 
forms  a  large  nodular  tumour  resembling  a  myoma,  but  differing  from 
it  in  its  rapidity  of  growth,  its  fixity,  and  the  presence  of  peritoneal 
fluid.    In  either  case  uterine  haemorrhage  is  likely  to  be  marked. 

Diagnosis. — The  malignant  nature  of  polypoid  sarcoma  has 
often  been  overlooked  from  failure  to  investigate  microscopically  the 
tissue  removed.  When  a  large  mass  can  be  felt  from  the  abdomen  a 
diagnosis  of  myoma  may  be  made  and  operative  treatment  postponed 
under  this  error.  The  rapidity  of  growth  and  the  signs  of  ascites 
should  awaken  suspicion. 

Sarcoma  of  the  cervix  is  very  rare.  A  peculiar  form  is  occasionally 
seen  in  young  children,  in  which  the  surface  of  the  mass  is  studded  with 
numerous  elevations  (grape-like  sarcoma).    In  adults  it  most  commonly 


1046 


THE    UTERUS 


assumes  a  polypoid  form.  The  symptoms  are  those  of  haemorrhage 
and  pain,  and  the  only  possible  treatment  is  wide  removal,  preferably 
by  Wertheim's  method  (see  p.  1024). 

UTERIXE    POLYPS 

Symptoms. — Five  varieties  of  uterine  polyps  are  found. 
1.  Adenomatous  and  cystic  polyps  (mucous  polyps). — The  structure 
of  the  growth  is  similar  to  that  of  those  occurring  in  the  cervix  (see 

p.  1017).  except 
that  the  glands  are 
tubular,  not  race- 
mose (Fig.  606). 
The  early  symptom 
is  menorrhagia  and 
irregular  loss,  which 
later,  as  the  growth 
extrudes,  becomes 
continuous. 

2.  Myomatous 
polyps. — The  symp- 
toms are  those  of 
a  submucous  my- 
oma, as  described 
at  p.  1036.  The 
loss  is  more  strictly 
periodic  than  that 
associated  with 
mucous  poly  p  a . 
the  tumour  having 
little  vascularity. 

3.  Placental  polyps. — Occasionally  a  portion  of  the  gestation  pro- 
ducts after  abortion  or  labour  remains  adherent  to  the  uterine  wall  and 
becomes  partially  organized.  Such  pedunculated  masses  occasion 
more  or  less  continuous  loss,  dating  from  the  termination  of  the 
pregnancy. 

4.  Malignant  polyps. — Sarcoma  is  the  only  form  of  malignant 
growth  that  commonly  becomes  actually  polypous.  The  symptoms  of 
these  growths  have  been  dealt  with  already  (p.  1045). 

Diagnosis. — So  long  as  the  polyp  is  contained  entirely  within 
the  corpus,  its  presence  can  only  be  discovered  after  dilating  the 
cervix.  It  may  be  suspected,  however,  when  with  bleeding  and 
some  uterine  enlargement  the  cervical  canal  is  found  unnaturally 
patent. 

Treatment. — The  cervix  having  been  dilated,  the  polyp  should 


Fig.  606. — Adenomatous  mucous  polyp,  the  in- 
flammatory stroma  containing  elongated  hyper- 
trophic glands. 


SALPINGITIS  1047 

be  removed  by  torsion  and  evulsion,  ezcepl  in  the  case  of  large  myoma- 
tous tumours  (see  p.  L041),  After  the  removal  of  an  adenomatous  oi 
cystic  polyp  the  mucosa  Bhould  1"'  curetted.  If  the  polyp  be  found 
in  be  malignant,  total  extirpation  of  the  uterus  and  adnexa  musi  be 
performed. 

THE  FALLOPIAN  TUBE 

SALPINGITIS 

Pathology.-  In  the  vasl  proportion  of  cases  the  route  of  tubal 
infection  is  through  the  uterus.  Thus  salpingitis  follows  on  endome- 
tritis of  puerperal,  postabortional,  gonorrhoea!,  or  postoperative  origin. 
Occasionally,  however,  it  is  me1  with  in  virgins  in  whom  uone  of  these 
causes  arc  in  operation,  and  in  such  cases  it  is  either  due  to  1 1 1  *  -  upward 
extension  of  a  simple  cervicitis  (see  p.  1008),  or  is  primary  in  the  tube 
itself.    These  primary  forms  are  almost  always  tuberculous. 

Rarely  the  tube  may  be  infected  through  the  abdominal  ostium 
from  an  appendicular  abscess  or  a  tuberculous  peritonitis. 

Acute  salpingitis  may  be  suppurative  or  non-suppurati\  >\ 

1.  Acute  suppurative  salpingitis. — The  tube  is  swollen  and  red  ;  the 
peritoneum  covering  it  and  the  adjacent  parts  is  injected,  and  soft 
adhesions  unite  it  to  the  omentum  and  to  neighbouring  coils  of  gut. 
The  tube  wall  and  plica-  are  infiltrated  with  polymorphonuclear  leuco- 
cytes,  and  the  lining  epithelium  is  largely  destroyed,  while  the  lumen 
contains  pus.  The  mesosalpinx  is  thickened  by  diffuse  lymphangitis, 
the  ovary  is  adherent  and  may  contain  thin-walled  cysts  due  to  acute 
serous  exudation  into  the  follicles,  whilst  the  peritoneum  in  the  neigh- 
bourhood is  often  raised  in  irregular  blebs  by  serous  exudate.  In  the 
most  acute  cases  there  is  a  direct  outpouring  of  pus  through  the 
abdominal  ostium  into  the  peritoneal  cavity.  More  commonly,  how- 
ever, the  tubal  fimbria?,  by  swelling  and  adhesion,  rapidly  occlude  the 
opening,  the  pus  collects  in  the  tube,  and  thus  a  pyosalpinx  is  formed. 
(Fig.  607.) 

On  account  of  the  fixity  of  its  mesosalpingeal  border  a  distended 
Fallopian  tube  assumes  a  curved  shape,  curling  downwards  and  inwards. 
Thus  the  tube  usually  almost  encircles  the  ovary,  and,  as  a  rule,  its 
lower  end  is  adherent  to  the  floor  of  the  recto-uterine  pouch. 

Acute  salpingitis  is  commonly  bilateral.  The  subsequent  fate  of  a 
pyosalpinx  varies.  It  ma}-  spontaneously  discharge  into  the  rectum 
to  which  it  lias  previously  become  adherent  ;  more  rarely  it  may  empty 
itself  into  the  vagina,  bladder,  or  uterus  ;  exceptionally  its  wall  may 
give  way  and  the  pus  escape  into  the  peritoneal  cavity.  More  often 
it  becomes  surrounded  by  a  mass  of  adhesions  to  the  uterus,  the  broad 
ligament,  the  bowel,  and  the  omentum,  and  thus  becomes  sequestered 
(see  Chronic  Salpingitis). 


1048 


THE   FALLOPIAN   TUBE 


Tubo-ovarian  abscess. — An  acute  pyosalpinx  is  frequently  com- 
plicated by  one  or  more  follicular  abscesses  of  the  ovary  on  the 
same  side.    Occasionally  the  cavity  of  the  pyosalpinx  communicates 

with  the  cavity  of  the  ovarian 
abscess,  a  retort-shaped  swelling 
being  formed  which  tends  to 
burrow  in  the  broad  ligament. 
(Fig.  608.) 

2.  Acute  nonsuppurative  sal- 
pingitis.—hi  less  severe  infec- 
tions, suppuration  may  not 
occur.  In  such  cases  the  tube,  if 
distended,  contains  a  serous  fluid, 
often  turbid  and  discoloured 
(acute  hydrosalpinx).  Occasion- 
ally, considerable  haemorrhage 
occurs  into  the  tube  lumen. 
The  result  is  a  hydro-hsemato- 
salpinx  (acute  hemorrhagic  sal- 
pingitis). In  other  resjpects 
the  anatomy  of  the  diseased 
tube  is  the  same  in  non- 
suppurative as  in  suppurative 
salpingitis  ;  but  so  long  as  sup- 
puration has  not  occurred,  spontaneous  resolution  is  possible. 

Chronic  salpingitis. — Chronic  salpingitis  is  usually  the  sequel  of 
the  acute  variety,  but  occasionally  cases  are  met  with  in  which  no 

history  of  the  latter  is  forthcoming. 
Some  of  these  are  due  to  tubercu- 
lous disease. 

Three  conditions  may  be  en- 
countered— (1)  chronic  pyosalpinx, 
(2)  chronic  hydrosalpinx,  (3)  chronic 
fibrotic  salpingitis. 

1.  Chronic  pyosalpinx. — An  old 
pyosalpinx  which  has  become 
densely  adherent  to  the  adjacent 
parts,  together  with  the  thickened 
mesosalpinx  and  infiltrated  omen- 
tum, forms  a  conglomerate  mass  of 
which  the  distended  tube  forms  only  a  part.  The  ovary,  surrounded 
by  adhesions  and  affected  with  peripheral  sclerosis,  often  becomes  the 
seat  of  multiple  follicular  cysts  which  in  time  may  totally  destrov  the 
organ. 


Fig.  607. — Uterus  with  pyosalpinx 
attached.  The  ovary  is  fairly 
healthy. 


Fig.  608. — Tubo-ovarian  abscess. 


CHRONIC    HYDROSALPINX 


1049 


The  pus,  if  secondarily  infected  by  organisms  from  the  bowel,  may 
be  very  fetid.  Jt  is  an  interesting  Eact,  however,  that  the  pus  is  often 
sterile,  the  bacteria  having  perished  from  prolonged  sequestration. 

2.  Chmnio  hydrosalpinx. — The  abdominal  ostium  of  an  inflamed 
tube  becomes  occluded  in  one  of  two  ways.  In  the  first,  adhesion  takes 
place  between  the  fimbriae  and  the  adjacent  ovary  or  broad  ligament. 
In  the  second,  the  oedema  of  the  muscular  coal  causes  the  tubal  peri- 
toneum gradually  to  overfold  the  fimbriae  so  that  they  appear  to  indrau 
until  they  disappear  altogether,  and  the  peritoneal  surfaces  adhere 
over  them.  The  occlusion  soon  leads  to  accumulation  in  the  tube  of 
the  secretion  from  its  walls.  A  pyosalpinx  or  hydrosalpinx  is  thus 
formed.     In  the  latter 

case  the  accumulated 
fluid  is  clear  in  colour 
and  odourless. 

A  hydrosalpinx  as- 
sume s  the  same 
general  curve  as 
pyosalpinx.  but  even 
more  markedly  be- 
cause,  as  a  rule,  it  is 
less  tethered  by  adhe- 
sions. (Fig.  609.)  It 
may  attain  a  large 
size,  and  is  surrounded 
more  or  less  by  ad- 
herent omentum  and 
bowel.  Both  tubes 
are  usually  affected. 

A  hydrosalpinx  may  intermittently  discharge  through  the  uterine 
ostium,  and  may  on  occasions  undergo  axial  rotation,  producing 
symptoms  like  those  of  a  twisted  ovarian  cyst. 

,  Tubo-ovarian  cyst. — For  reasons  already  stated,  the  ovary  adjacent 
to  a  hydrosalpinx  frequently  contains  follicular  cysts.  Sometimes  a 
cyst  in  the  ovary  communicates  with  the  tube,  the  whole  forming 
a  very  characteristic  retort-shaped  swelling.  The  history  and  symp- 
toms of  a  tubo-ovarian  cyst  are  the  same  as  those  of  a  hydrosalpinx. 

3.  Chronic  fibrotic  salpingitis. — In  many  cases  of  chronic  salpingitis 
the  inflammatory  changes  are  most  marked  in  the  substance  of  the 
tube  wall,  and  there  is  comparatively  little  exudation  into  its  lumen. 
The  tubal  plicae  become  much  kypertrophied,  and  the  epithelium 
covering  them  tends  to  dip  downwards,  forming  many  crypts,  and 
therefore  presenting  an  adenomatous  appearance  under  the  micro- 
scope  (Fig.  610).     The  wall  becomes  greatly  thickened,  at  first  by  cell 


Fig.  609. — Uterus  with  large  hydrosalpinx 
attached. 


1050 


THE   FALLOPIAN  TUBE 


proliferation  and  oedema,  and  later  by  fibrosis.  The  tube  curls  down- 
wards and  becomes  densely  adherent  to  the  ovary,  the  back  of  the 
broad  ligament,  the  uterus,  the  intestine,  especially  the  pelvic  colon, 
and  the  omentum.  The  ovary  is  often  cystic  as  well.  The  result  is 
a  conglomerate  mass  lying  to  one  side  of  the  back  of  the  uterus,  and 
commonly  referred  to  as  a  "  diseased  appendage/' 

Clinical  features.  Acute  salpingitis.  Symptoms.  —  The 
symptoms  of  acute  salpingitis  are  those  of  pelvic  peritonitis.  The  onset 
is  sudden,  with  severe  pain  referred  to  the  lower  abdomen,  the  tem- 
perature and  pulse- 
rate  are  high,  and 
there  may  be  some 
sickness.  The  bowels 
are  constipated,  or 
when  opened  occa- 
sion much  pain. 
Micturition  may 
also  be  painful. 

Physical  signs. — 
From  the  outset 
there  are  tender- 
ness and  rigidity 
over  the  lower  ab- 
domen, perhaps 
more  marked  on  one 
side.  After  a  day 
or  two  an  indefinite 
swelling  rises  above 
the  pubis.  This 
swelling  may  be 
mesial  in  position, 
or  more  marked  to 
one  side  of  the 
middle  line.  Resonance  is  only  partially  impaired  over  it,  because  it  is 
largely  made  up  of  adherent  coils  of  gut.  At  the  end  of  a  week  it  may 
have  attained  the  level  of  the  umbilicus,  and  have  become  much  more 
denned  and  dull.  On  vaginal  examination  nothing  but  great  tender- 
ness to  one  or  both  sides  of  the  uterus  is  first  noticed,  but  later  a  definite 
swelling  or  swellings  can  be  distinguished,  extending  from  the  sides  of 
the  uterus  into  the  pouch  of  Douglas.  Eventually,  in  bilateral  disease, 
a  large,  very  tender  mass  is  felt  behind  and  to  the  sides  of  the  uterus, 
which  it  tends  to  push  forwards.  The  mass  is  continuous  with  that 
felt  from  the  abdomen,  and  always  lies  in  front  of  the  rectum,  which 
it  may  compress  against  the  sacrum. 


Fig.  610. — Sclerotic  salpingitis. 

The   plicae  are  swollen  and   distorted,  and    the  subepithelial 

tissues   crowded    with    inflammatory  cells.      The   epithelium 

lies  proliferated,   forming  many  gland-like  spaces. 


SALPINGITIS 

Clinical  course.-  This  varies.  In  Eavouiable  oases  the  Bymptoms 
begin  to  subside  in  about  three  days,  and  after  a  period  ot  some  week 
or  two  oomplete  recovery  may  ensue.  More  commonly,  liowever, 
subsidence  is  only  partial,  a  permanently  tender  fixed  swelling  being 
Left  in  ilif  region  of  the  appendage,  accompanied  by  the  symptoms 
of  chronic  hydrosalpinx  or  fibrotic  salpingitis. 

In  the  more  severe  cases  (acute  pyosalpinx)  the  temperature  con- 
tinues to  rise  after  the  fourth  day,  and  becomes  markedly  remittent, 
indicating  the  Eormation  of  pus  in  the  tube.  Rigors  may  occur.  Three 
courses  are  now  possible.  In  the  first,  after  some  days,  a  discharge 
of  pus  from  the  rectum  may  indicate  spontaneous  evacuation  of  the 
retained  pus.  The  symptoms  may  greatly  ameliorate  alter  this  event, 
but  since  both  tubes  are  usually  affected  and  these  spontaneous  openin 
do  not  drain  well,  the  symptoms  after  initial  improvement  frequently 
recur.  In  the  second  course  no  spontaneous  discharge  occurs,  but  the 
patient  gradually  passes  into  a  state  of  chronic  fever  and  pain  with 
recurring  exacerbations  (chronic  pyosalpinx). 

Finally,  in  the  worst  cases,  namely,  those  in  which  pus  escapes 
through  the  abdominal  ostium  into  the  peritoneal  cavity,  the  symptoms 
of  generalized  peritonitis  may  be  present.  Except  in  this  event,  and 
the  still  rarer  one  of  spontaneous  rupture  of  the  distended  tube  into 
the  peritoneal  cavity,  it  is  uncommon  to  find  pus  actually  in  the 
peritoneum  in  cases  of  salpingitis. 

Chronic  salpingitis.  Symptoms.  —  The  symptoms  of  chronic 
salpingitis  vary  with  the  condition  of  the  diseased  tube. 

Where  a  pyosalpinx  is  present,  the  leading  feature  is  continual  pain 
and  tenderness  over  the  affected  tube  or  tubes,  with  recurring  exacer- 
bations accompanied  by  fever  and  sickness.  These  exacerbations  are 
often  synchronous  with  the  menses  and  are  provoked  by  exertion  or 
intercourse,  j.  Coitus  is  usually  impossible.  Intermittent  discharges  of 
pus  from  the  tube,  via  the  uterus,  may  take  place.  The  menses  are 
excessive,  prolonged  and  often  anticipated. 

In  hydrosalpinx  and  in  fibrotic  salpingitis  these  exacerbations  are 
not  so  marked,  but  pain  is  continual  in  the  lower  abdomen  on  one  or 
both  sides.     Dysmenorrhea,  dyspareunia,  and  sterility  are   present. 

All  forms  of  salpingitis  are  almost  constantly  accompanied  by 
endometritis  and  cervicitis,  the  svmptoms  of  which  are  also  present. 
The  uterus  is  often  retroverted,  especially  in  salpingitis  of  postparturi- 
tional  origin. 

Diagnosis.  Acute  salpingitis. — The  symptoms  of  ruptured 
tubal  gestation,  of  axial  rotation  of  an  ovarian  tumour  or  a  peduncu- 
lated myoma,  of  appendicitis,  of  a  suppurating  ovarian  cyst,  and  of 
acute  pelvic  cellulitis,  all  more  or  less  resemble  those  of  acute  salpingitis. 

The  physical  signs  of  ruptured  tubal  gestation  are  almost  identical 


io52  THE   FALLOPIAN   TUBE 

with  those  of  salpingitis,  but  there  is  less  tenderness,  the  pain  is 
markedly  unilateral,  the  patient  looks  exsanguined,  and  the  tempera- 
ture at  the  beginning  is  either  not  raised  or  is  actually  subnormal. 
A  history  of  previous  amenorrhcea  is  in  favour  of  tubal  gestation,  for 
though  the  period  may  be  suppressed  in  acute  salpingitis,  and  par- 
ticularly in  tubo-ovarian  abscess,  this  occurrence  follows  the  onset  of 
the  symptoms. 

Axial  rotation  of  a  tumour  is  distinguished  by  the  presence  of  a 
well-defined  tumour,  often  fluctuant  and  always  dull  on  percussion  in 
the  earliest  stages  of  the  attack.  The  mass  formed  by  acute  salpingitis 
is  never  definite  for  at  least  a  week,  rarely  fluctuates,  and  commonly 
is  partially  resonant. 

In  appendicitis,  as  a  rule,  the  location  of  the  symptoms  and  physical 
signs  is  different.  When,  however,  the  appendix  lies  low  down  on  the 
brim  of  the  pelvis,  inflammation  of  the  right  tube  may  be  closely 
simulated.  Sickness,  distension,  and  constipation  are  greater  with 
appendicitis  than  with  salpingitis.  Further,  a  patient  with  appendicitis 
is  more  ill  than  one  with  salpingitis  exhibiting  the  same  degree  of 
physical  signs.  If  a  definite  mass  can  be  felt  per  vaginam  in  the  position 
of  the  right  appendage,  the  case  is  probably  one  of  salpingitis. 

When  an  ovarian  cyst  in  the  pelvis  suppurates,  the  signs  and  symp- 
toms of  salpingitis  are  simulated.  Here  again  the  mass  is  from  the 
beginning  well  defined,  and  is,  moreover,  entirely  central  in  position. 

Pelvic  cellulitis  resembles  acute  salpingitis  in  its  abrupt  onset  with 
fever  and  pain.  The  symptoms  are  less  severe,  however,  and  at  first 
there  may  be  little  to  make  out  per  abdomen  ;  later,  when  a  swelling 
appears  there  it  is  markedly  lateral,  and  extends  outwards  towards 
the  iliac  fossa.  On  vaginal  examination  a  typical  lateral  cellulitis  (the 
only  form  that  could  be  confounded  with  salpingitis)  stretches  outwards 
from  the  uterus  to  the  side  wall  of  the  pelvis.  The  induration  arches 
downwards,  comes  into  relation  with  the  lateral  vaginal  wall,  and 
is  not  felt  through  the  posterior  fornix.  It  is  to  be  remembered,  how- 
ever, that  more  or  less  cellulitis  of  the  upper  part  of  the  broad  ligament 
usually  accompanies  salpingitis. 

Chronic  salpingitis. — The  mass  formed  by  chronic  salpingitis, 
especially  an  old  pyosalpinx,  may  be  so  solid  and  large  as  to  simulate 
an  ovarian  tumour,  or  a  myoma  attached  to  the  side  of  the  uterus. 
From  these  it  is  distinguished  by  its  tenderness,  and  by  the  history 
and  symptoms  of  inflammation. 

A  diseased  appendage  lying  behind  a  retroverted  uterus  may  be 
mistaken  for  the  retroflexed  fundus  ;  it  can  be  differentiated  by  careful 
bimanual  examination  and  the  passage  of  a  sound  under  an  anaesthetic. 

Tubal  carcinoma  forms  a  mass  impossible  to  diagnose  from  chronic 
salpingitis  except  by  operation. 


SALPINGITIS  ro53 

In  chronic  cellulitis  and  encysted  broad-ligamenl  abscess  the 
mass  is  strictly  unilateral,  displaces  the  uterus  t<»  the  opposite  side, 

and  does  not  extend  behind  it. 

The  diagnosis  of  the  r.nui  oondtiion  of  a  chronically  inflamed  tube 
is  important.  A  pyosalpinx  may  be  Buspected  it'  recurring  attacks  of 
fever  arc  a  feature  of  the  case,  <>r  if  the  mass  is  very  large  and  tender. 
A  hydrosalpinx  may  be  Eell  as  a  fluctuating  elongated  swelling,  and 
is  much  less  tender  than  a  pyosalpinx.  Fibroin-  salpingitis  is  distin- 
guished by  the  smaller  size  of  the  mass,  its  fixity  and  hardness,  and 
by  the  fad  thai  the  symptoms  are  those  of  chronic  pelvic  pain  without 
exacerbations.  A  tuberculous  origin  is  to  he  suspected  where,  in  a 
virgin,  a  considerable  mass  is  found,  unexplained  by  the  history. 

In  conclusion,  the  frequency  of  diagnostic  error  in  these  cases,  even 
by  the  most  expert,  must  be  strongly  emphasized  ;  the  surgeon's 
primary  duty  is  to  determine  the  correct  treatment,  rather  than  the 
actual  anatomical  nature  of  the  swelling  felt. 

Prognosis. — A  patient  rarely  dies  of  salpingitis.  In  acute  cases 
that  rapidly  subside  without  the  formation  of  pus  the  tube  may 
possibly  return  to  the  normal,  although  in  most  eases  the  abdominal 
ostium  probably  remains  permanently  sealed  up,  and  so  produce? 
sterility. 

If  pus  has  formed,  the  tube  is  permanently  disorganized.  In  chronic 
cases  all  hope  of  restitution  to  the  normal  must  be  abandoned.  The 
longer  the  duration,  the  greater  the  likelihood  of  secondary  disorganiza- 
tion of  the  ovary  by  adhesion,  peripheral  sclerosis,  and  follicular  cyst 
formation. 

Treatment.  Acute  salpingitis. — Whenever  possible,  operative 
measures  should  be  postponed  until  the  acute  stage  is  passed,  (1)  because 
if  no  pus  forms  the  condition  may  entirely  subside,  and  (2)  because  an 
operation  during  the  height  of  the  attack  is  much  more  difficidt  and 
dangerous,  for  the  tubal  contents  are  virulent,  the  tissues  are  so  soft 
and  vascular  that  ligatures  cut  through  them,  the  bowel  wall  is  friable 
and  easily  tears,  and  the  patient's  general  condition  is  unsatisfactory. 

Immediate  operation  is.  however,  proper — (1)  when  the  severity 
and  extent  of  the  peritonitis  suggest  a  direct  outpouring  of  pus  into 
the  peritoneal  cavity,  and  (2)  when  the  cause  of  the  symptoms  cannot 
with  reasonable  certainty  be  diagnosed. 

If  it  be  decided  to  temporize,  hot  antiseptic  fomentations  should 
be  applied  to  the  lower  abdomen,  the  patient  put  on  a  liquid  diet,  the 
bowels  opened  every  other  day  by  an  enema,  and  the  intestinal  dis- 
tension relieved  by  the  passage  every  six  hours  of  a  lone;  rectal  tube. 
Paiirmay  be  met  by  morphia  cautiously  given,  or  better  by  Bromidia. 

Directly  the  temperature  has  fallen  below  100°  F.,  operation  should 
be  undertaken,   supposing  a   considerable   mass   still  remains  in  the 


1054  THE   FALLOPIAN   TUBE 

pelvis,  for  undue  delay  allows  the  formation  of  strong  adhesions,  and 
increases  the  likelihood  of  ovarian  disorganization. 

Where  the  tube  alone  is  affected,  salpingectomy  is  generally  fehe 
operation  of  choice.  It  consists  in  dissecting  the  tube  off  the  meso- 
salpinx and  dividing  it  at  the  uterine  cornu  ;  or. if  it  be  desired  to 
remove  the  entire  structure,  a  wedge-shaped  portion  of  the  cornu 
containing  its  interstitial  segment  is  excised  and  the  gap  closed  by 
sutures. 

In  some  cases  the  ovary  is  disorganized,  contains  collections  of 
pus,  or  is  conjoined  to  the  tube  in  a  tubo-ovarian  abscess  ;  then  the 
removal  of  the  whole  appendage  is  required  (salpingo-ovphorectomy). 
The  tube  and  ovary  having  been  separated  from  the  surrounding 
adhesions,  the  ovarico-pelvic  ligament  is  clamped  and  divided,  and, 
the  inner  attachments  of  the  appendage  being  ligatured  in  halves, 
the  tube  and  ovary  are  removed.  The  ovarico-pelvic  ligament  is  then 
ligatured,  and  all  oozing  stopped. 

Where  acute  metritis  coexists  with  an  acute  double  pyosalpinx  it 
is  sometimes  advisable  to  remove  the  whole  uterus  as  well,  especially 
if  both  ovaries  have  had  to  be  excised,  for  the  uterus  is  useless  after 
the  removal  of  both  appendages,  and  if  conserved  may  be  the  source 
of  discharge  and  pain. 

After  all  operations  for  acute  salpingitis,  it  is  advisable  to  drain 
the  pelvis  for  a  day  or  two. 

Chronic  salpingitis. — The  treatment  of  chronic  salpingitis  varies 
with  the  presumed  condition  of  the  tube.  A  pyosalpinx  must,  of 
course,  be  removed  ;  and  the  same  course  must  be  adopted  for  any 
considerable  inflammatory  enlargement  of  the  appendage,  whether 
the  presence  of  pus  be  diagnosed  or  not.  A  hydrosalpinx  should  be 
similarly  treated.  Fibrotic  salpingitis  of  old  standing,  and  forming 
but  a  little  mass,  need  not  be  interfered  with  unless  it  gives  rise  to 
sufficient  pain  and  disability  to  justify  the  operation. 

The  ideal  operation  for  chronic  salpingitis  is  salpingostomy,  which 
consists  in  freeing  the  tube  from  its  adhesions,  fashioning  a  new  abdo- 
minal ostium  by  slitting,  evacuating  the  contents,  and  stitching  back 
the  edges  of  the  opening  so  as  to  evert  the  mucous  membrane.  Unfor- 
tunately, this  can  only  be  done  where  the  disease  is  slight  and  the 
tube  wall  relatively  healthy,  as  in  many  cases  of  hydrosalpinx. 

In  all  cases  of  pyosalpinx,  and  in  others  where  the  conservation 
of  the  tube  is  either  impossible  or,  on  account  of  the  patient's  age, 
useless,  salpingectomy  or  salpingo-oophorectomy  must  be  performed. 
The  former  should  always  be  preferred  if  the  ovary  be  reasonably 
healthy. 

In  some  cases  of  double  pyosalpinx  with  extensive  dense  matting 
of  the  pelvic  organs,  removal  of  the  tubes  is  facilitated  by  performing 


TUBAL    PREGNANCY  1055 

subtotal  hysterectomy  as  well.    Lastly,  where  both  append 
diseased  as  to  require  removal,  and  the  uterus  is  the  seat  <>f  chronic 
inflammatory  changes,  producing  monorrhagia  and  continual  discharge, 
total  hysterectomy  should,  in  addition,  be  carried  out. 

TUBAL    GESTATION 

Etiology.  The  cause  of  tulul  gestation  is  unknown.  Investi- 
gation of  early  cases  Bhows  the  tube  to  I"'  normal  excepl  .it  the  site 
of  the  pregnancy. 

Repeated  tubal  1  urs  so  frequently  as  to  indicate  some 

peculiarity  in  certain  individuals  mclining  them  to  this  disaster.  The 
event  most  commonly  occurs  cither  in  first  pregnancies  or  after  some 
a  of  sterility. 

The  suggestions  of  etiological  relationship  to  salpingitis,  to  tubal 
•sis  or  diverticula,  or  to  the  passage  of  the  ovum  from  the  ovary 
<>t  the  opposite  side  are  not  supported  by  research. 

Pathology. — The  oosperm  burrows  through  the  tubal  epithelium 
and  embeds  itself  in  the  muscular  wall  by  means  of  its  trophoblast.  It 
develops  there  in  a  cavity  known  as  the  gesta  formed  in  the 

maternal  tissues  by  the  destructive  action  of  the  trophoblastic  cells. 
The  small  track  into  the  tube  wall  is  early  occluded  by  fibrinous  de- 
posit,  so  that  the  gestation  is  at  first  entirely  intramural  in  position. 
(Fig.  611.) 

Primary  rupture  of  the  gestation  sac. — The  continued  growth 
of  the  ovum  leads  to  rupture  of  the  gestation  sac  usually  within  eight 
weeks  of  the  beginning  of  gestation.  Kupture  is  brought  about  (1) 
by  the  erosion  of  the  trophoblast  and  (2)  by  extravasation  of  blood 
into  the  gestation  sac  when  some  large  maternal  vessel  is  opened 
up  by  the  invading  trophoblastic  cell-. 

Primary  rupture  of  the  gestation  sac  may  occur  in  one  of  five 
directions. 

1.  Intraperitoneal  rupture. — The  sac  perforate.-  through  the  serous 
covering  of  the  tube  into  the  peritoneal  cavity.  This  disaster,  usually 
seen  in  isthmic  gestation,  because  of  the  small  size  of  the  tube  there, 
produces  the  most  severe  symptoms.  Bleeding  is  profuse,  and  may 
cause  death  in  two  or  three  hours.  This  is  the  more  striking  because 
the  gestation  is  often  less  than  a  month  old,  the  patient  bleeding 
to  death  from  a  tubal  enlargement  not  bigger  than  a  marble. 
(Fig.  612.) 

2.  Intraligamentous  rupture. — Occasu  inally  the  sac  perforates  between 
the  layers  of  the  mesosalpinx.  A  broad-ligament  hematoma  results, 
and  may  attain  a  large  size,  but  the  bleeding  is  much  less  rapid  than 
in  the  preceding  variety  and  the  symptoms  are  proportionately  less 
severe. 


1056 


THE   FALLOPIAN  TUBE 


3.  Intratubal  rupture  {tubal  abortion). — In  ampullary  gestation  the 
sac  commonly  ruptures  into  the  tube  lumen.  The  blood  flows  into 
the  tube  and,  escaping  through  the  abdominal  ostium,  drips  into  the 
pelvis,  and  by  its  accumulation  forms  a   hematocele.      If  the  ostium 


Fig.  611. — Transverse  section  of  a  ruptured  three -weeks'  tubal  pregnancy. 
The  gestation  sac  is  entirely  intramural.  The  lumen  of  the  tube  is 
somewhat  dilated. 

A,  Mesosalpinx  ;  B,  gestation  sac;  C,  fibrin   mass;   I>    site  of  rupture  ;   E  'wall  of  gestation 
sac  infiltrated  by  foetal  cells. 

is  already  closed  or  becomes  blocked  by  clot  the  tube  is  distended 
and  a  hcematosalpinx  is  formed  ;  its  contents  often  leak  through  the 
uterine  ostium,  causing  continuous  or  intermittent  vaginal  loss. 

Occasionally  the  "  blood  drip  "  from  the  abdominal  ostium  may 
become  encysted  around  this  orifice  ('peritubal  hematocele). 

i.  Intramural  rupture  (tubal  mole). — This  form  of  primary  rupture 


TUBAL  PREGNANGYs  PATHOLOGY 


i  "57 


of  tin-  gestation  Bac  is  due  bo  its  Budden  distension  by  extia\  I 

blood.  The  sac  wall  gives  way  ;in<l  t  be  U 1  burrows  along  I  be  muscu- 
lature of  the  tube,  forming  an  intramural  bsematoma,  in  the  midst  of 
which  lies  the  ovum,  usually  completely  separated  from  its  attachment 
to  the  maternal  tissues.  The  blood  dots,  and  a  "tubal  blood  mole" 
is  formed  (Fig.  613). 

This  may  remain  sequestered  in  the  tube  wall  and  possibly 
eventually  become  absorbed  ;  more  often,  however,  the  sac  gives  way 
iu  a  new  direction  owing  to  the  Eacl  that  the  trophoblastic  cells  in 
the  infiltration  zone  remain  active  after  the  festal  nidimenl  has 
perished.  This  secondary  rupture  may  be  intraperitoneal  or  intra- 
tubal.  Iu  cither  case  the  blood  mole  becomes  extruded,  and  is 
found  either  loose  in 
the  peritoneal  cavity  or 
in  process  of  extrusion 
from  the  tube  lumen. 

5.  Intra-uterinc  rwp- 
ture. — This  can  only 
happen  in  gestation  in 
the  interstitial  segment 
of  the  tube,  and  is  a 
rare  event.  It  would 
produce  the  signs  of 
miscarriage  with  severe 
bleeding,  and  its  oc- 
currence is  probably 
usually  overlooked. 

Secondary  ruptures. — In  most  cases  of  tubal  gestation  several 
ruptures  of  the  gestation  sac  and  tube  have  occurred  before  opera- 
tion. Thus,  after  primary  intramural  rupture,  secondary  rupture 
of  the  sac  into  the  tube  lumen  or  peritoneum  may  occur.  In  other 
cases  the  hematosalpinx  formed  by  primary  intratubal  rupture  may 
subsequently  give  way.  This  fact  accounts  for  the  usual  history  of 
several  attacks  of  pain  and  faintness  at  intervals  of  some  hours 
or  days.  Many  of  these  secondary  ruptures  produce  quite  tem- 
porary escapes  of  blood  through  the  apertures  being  quickly  closed 
by  blood  clot. 

Secondary  sacs  (intraperitoneal  and  intraligamentous  gestation). 
— Rupture  of  the  primary  gestation  sac,  which  always  occurs  before 
the  third  month,  usually  kills  the  embryo,  but  occasionally,  if  the 
chorionic  villi  retain  their  attachment  to  the  tube  wall,  the  gestation 
survives  and  continues  to  grow  in  a  secondary  sac  either  in  the  peritoneal 
cavity  or  between  the  layers  of  the  broad  ligament.  (Fig.  614.)  In 
the  first  case  the  sac  wall  is  formed  by  the  tube,  the  back  of  the  broad 

IP 


Fig.  G12. — Acute  intra- 
peritoneal rupture  of  an 
early  tubal  gestation 
(half  actual  size). 


Fig.  01  3.— Tubal 
mole  in  section. 


io53 


THE   FALLOPIAN  TUBE 


ligament  and  uterus,  adherent  intestine  and  omentum,  and  the  ab- 
dominal parietes.  In  the  second,  the  sac  expands  the  broad  ligament,, 
pushes  the  uterus  to  the  opposite  side  of  the  pelvis,  and  gradually  rises 
into  the  abdomen  by  stripping  the  peritoneum  off  the  side  wall  of  the 
pelvis  and  iliac  fossa  until  at  term  it  may  lie  nearly  centrally  under 
the  peritoneum  in  front  of  the  spine  and  great  vessels. 

A  gestation  in  a  secondary  sac  may  rupture,  but  it  sometimes  goes 
on  to  term,  when  "  spurious  labour  "  takes  place,  the  uterus  expelling 
a  decidual  cast.     The  foetus  then  dies,  usually  within  a  month,  and  is 


Fig.  614. — Ruptured  tubal  pregnancy  at  four  months. 

The  sac  is  tubo-peritoneal.     The  opposite  tube  is  in  a  condition  of  hematosalpinx. 

gradually  converted  into  adipocere  and  subsequently  calcified,  forming 
a  lithopsedion.  A  sequestered  extra-uterine  foetus  may  remain  in  the 
abdomen  for  forty  years  without  causing  trouble.  More  commonly, 
however,  the  sac  inflames  and  suppurates,  multiple  sinuses  are  formed 
communicating  in  the  case  of  intraperitoneal  sacs  with  the  bowel  or 
umbilicus,  and  in  the  case  of  intraligamentous  sacs  with  the  skin 
above  the  groin,  the  bladder,  or  the  vagina. 

Condition  of  the  uterus. — The  uterus  in  extra  -uterine  pregnancy 
enlarges  so  that  at  full  term  it  is  about  the  size  of  a  three-months' 
intra-uterine  pregnancy.  A  decidual  hypertrophy  of  the  endometrium 
also  occurs,  and  may  be  cast  off  entire  after  rupture  of  the  primary 
gestation   sac.     This    only  occurs,  however,  in  a  minority  of  cases  ;: 


TUBAL   PRKGNANCY  :    SYMPTOMS  1059 

in  the  remainder  it  is  passed  as  small  shreds  that   escape  notice  in 
the  general  loss. 

Symptoms  and  signs. — Until  the  gestation  sac  ruptures,  the 

symptoms  of  tubal   pregnancy   are  indistinguishable    from  those  of 
intrauterine   pregnancy.     Amenorrhoea    and    morning    Bickness    are 

present,  and  in  due  course  the  breasts  enlarge. 

The  symptoms  and  signs  produced  by  the  rupture  of  the  gestation 

sac  are  very  varied,  and  can  only  he  interpreted  in  the  light  of  a  full 
understanding  of  the  pathology  of  the  condition. 

1.  Acute  intraperitoneal  rupture — When  the  primary  gesta- 
tion sac  ruptures  acutely  into  the  peritoneal  cavity  the  symptoms 
are  most  fulminant.  The  patient  is  suddenly  seized  with  severe  pain 
and  faintness,  and  soon  presents  all  the  s)^mptoms  of  urgent  internal 
hrernorrhage.  The  skin  is  blanched  and  cold,  the  pulse  very  last  and. 
small,  the  respirations  gasping,  and  the  mental  condition  one  of  acute 
anxiety.  The  pain  is  referred  to  the  abdomen  generally.  On  examina- 
tion, localizing  signs  may  be  slight  or  absent  altogether,  for  the  tubal 
enlargement  is  small  and  liquid  blood  in  the  peritoneum  produces  no 
tangible  tumour,  though  after  a  while  abdominal  rigidity  and  slight 
distension  may  be  noticed.    These  cases  may  end  fatally  in  a  few  hours. 

2.  Intramural  and  intratubal  rupture. — Intramural  rupture 
produces  an  attack  of  acute  pain  due  to  the  rapid  swelling  of  the  tubal 
tissues.  If  the  gestation  is  destroyed  by  this  event,  no  further  symptoms 
may  occur,  and  all  that  can  be  found  is  a  slight  enlargement  in  the 
continuity  of  the  tube.  More  commonly,  however,  it  is  followed  by 
a  secondary  rupture  into  the  lumen  of  the  tube  or  into  the  peritoneum, 
in  which  case  the  attack  of  pain  is  repeated,  with  more  severity.  Faint- 
ness and  the  symptoms  of  internal  haemorrhage  are  present,  and  the 
signs  of  a  pelvic  hematocele  develop. 

Intratubal  rupture  may,  however,  be  the  primary  event,  in  which 
case  the  first  attack  of  pain  is  more  violent  and  faintness  more  constant, 
The  signs  depend  upon  whether  the  abdominal  ostium  is  patent  or  not. 
In  the  first  case  the  blood  finds  its  way  into  the  pelvis  and,  gradually 
mounting,  floats  up  the  intestines  and  omentum.  Blood  in  the  peri- 
toneum acts  as  an  irritant  to  that  membrane,  and  it  has  been  shown 
that  its  presence  there  is  followed  in  a  short  time  by  the  appearance  of 
micro-organisms.  A  plastic  peritonitis  is  thus  set  up,  matting  the  intes- 
tines and  omentum  around  the  collection  of  blood,  now  known  as  a 
hcemaiocele.  In  the  second  event,  all  the  blood  collects  in  tlie  tube 
lumen,  and  a  large  hcematosalfinx  is  produced.  In  most  cases  the 
double  condition  obtains,  i.e.  part  of  the  blood  is  poured  into  the 
pelvis  and  part  is  retained  in  the  tube. 

Intratubal  rupture  (tubal  abortion),  either  primary,  or  secondary  to 
intramural  rupture,  is  the  commonest  termination  of  tubal  pregnancy, 


1060  THE   FALLOPIAN  TUBE 

and  its  symptoms,  namely,  recurring  attacks  of  abdominal  pain  and 
faintness,  associated  with  bleeding  from  the  uterus  and  the  formation 
of  a  pelvic  mass,  are  those  classically  associated  with  extra-uterine 
gestation.  The  recurring  pain  is  produced  by  the  successive  ruptures 
of  the  tube  wall  with  each  fresh  outburst  of  bleeding,  while  the  uterine 
haemorrhage  is  chiefly  due  to  the  leakage  of  the  haematosalpinx  through 
the  uterine  ostium,  though  part  of  it  may  be  caused  by  the  separation 
of  the  intra-uterine  decidua. 

The  mass  felt  is  a  conglomerate  consisting  of  the  swollen  tube, 
peritoneal  lymph  and  adhesions,  the  matted  intestine  and  omentum,  and 
the  blood  free  in  the  pelvis.  It  appears  after  the  lapse  of  some  days, 
and  becomes  increasingly  defined  and  hard  as  the  blood  clots. 

Where  a  hsematocele  is  formed,  the  mass  lies  directly  in  front  of 
the  rectum,  and  the  uterus  is  pressed  forwards  on  to  the  bladder,  but 
if  a  hgematosalpinx  alone  is  present  the  swelling  is  more  to  one  side. 
Fever  is  often  present  after  the  first  day  or  two,  owing  to  the  resultant 
peritonitis. 

3.  Intraligamentous  rupture. —Eupture  of  the  primary 
gestation  sac  into  the  broad  ligament  is  announced  by  severe  pain 
referred  to  the  lower  abdomen  on  that  side,  and  in  a  short  time 
an  indefinite  swelling  in  the  region  of  the  broad  ligament  is  felt.  This 
swelling  becomes  more  defined  and  enlarged,  every  increment  in  size 
produced  by  fresh  bleeding  being  accompanied  by  exacerbation  of 
the  pain. 

A  very  large  tumour  may  thus  be  formed,  displacing  the  uterus 
to  the  opposite  side,  and  mounting  up  into  the  abdomen  behind  the 
peritoneum  to  one  side  of  the  middle  line. 

4.  Intraperitoneal  and  intraligamentous  pregnancy. — A 
living  gestation  in  the  peritoneal  cavity  or  between  the  layers  of 
the  broad  ligament  forms  an  elastic  fluctuating  tumour  lying  either 
behind  the  uterus  (intraperitoneal)  or  to  one  side  of  it  (intraliga- 
mentous). Definite  uterine  enlargement  is  present,  and  the  signs  of 
foetal  life  and  active  placental  circulation  may  be  detected  over  the 
tumour. 

There  is  usually  a  history  of  an  attack  of  pain  in  an  earlier  period 
of  the  pregnancy  corresponding  to  the  rupture  of  the  primary  gestation 
sac.  The  severity  of  the  symptoms  varies  :  some  patients  suffer  no 
more  discomfort  than  is  common  in  the  later  months  of  normal 
pregnancy;  others  have  persistent  pain  or  interference  with  the 
intestines  amounting  to  partial  obstruction. 

Secondary  sacs  sometimes  rupture,  the  foetus  escaping  among  the 
intestines ;  or  the  extra-uterine  placenta  may  accidentally  separate 
and  cause  internal  haemorrhage. 

5.  Sequestered  extra-uterine  pregnancy. — Where  sequestra- 


TUBAL    PREGNANCY:     DIAGNOSIS  1061 

lion  has  not  long  occurred  the  history  of  ;m  apparenl  pregnancy 
terminating  in  spurioua  labour  will  at  once  indicate  the  nature  of 
the  mass  felt.  Alter  many  years,  however,  the  history  may  be  in- 
definite, and  diagnosis  then  is  difficult  or  impossible.  Most  of  these 
cases  present  themselves  because  of  suppuration  round  the  sac,  and 
in  some  the  extrusion  of  foetal  bones  through  the  sinuses  formed 
will  elucidate  the  nature  <>{  the  condition.  In  others  it  can  only 
be  decided   by   operation. 

Diagnosis. — Acute  intraperitoneal  rupture  of  the  primary 
gestation  sac  may  be  mistaken  for  perforation  of  a  gastric  or  intestinal 
ulcer,  fulminant  appendicitis,  volvulus  and  other  forms  of  acutest 
intestinal  obstruction,  rupture  of  a  solitary  ovarian  abscess  or  ovarian 
blood  cyst,  or  acute  torsion  of  an  ovarian  or  uterine  tumour.  In  all 
these  catastrophes  the  striking  feature  is  the  suddenness  of  onset  of 
the  symptoms.  The  two  chief  points  that  distinguish  acute  tubal 
rupture  are  the  history  of  preceding  amenorrhcea  and  the  signs  of 
internal  haemorrhage,  as  compared  with  the  signs  of  shock  which 
characterize  most  of  the  other  disasters  mentioned. 

Rupture  of  an  ovarian  blood  cyst  or  severe  haemorrhage  from 
dehiscence  of  a  Graafian  follicle  produces  symptoms  indistinguishable 
from  acute  rupture  of  a  tubal  gestation,  but  the  history  of  amenorrhcea 
is  wanting.  Torsion  of  an  ovarian  cyst  may  cause  profuse  intracystic 
bleeding,  but  the  presence  of  a  tumour  from  the  outset  distinguishes 
it  from  the  ruptured  gestation,  in  which  a  mass  is  only  formed  after  a 
day  or  twro. 

The  symptoms  of  intratubal  rupture  (tubal  abortion),  which  are 
often  preceded  by  those  of  intramural  rupture  (the  formation  of  a 
tubal  mole),  are  more  likely  to  be  mistaken  for  salpingitis  and  pelvic 
peritonitis,  for  inflammation  or  subacute  torsion  of  an  ovarian  cyst, 
for  subacute  appendicitis,  or  for  abortion  of  an  intra-uterine  gestation. 
The  recurring  attacks  of  acute  pain  often  associated  with  a  bloody 
uterine  discharge,  and  sometimes  with  the  passage  of  a  cast,  are  classic- 
ally associated  with  tubal  gestation. 

The  history  of  preceding  amenorrhcea  is  an  important  diagnostic 
feature,  for  though  suppression  of  a  period  may  occur  with  acute 
salpingitis,  and  particularly  with  tubo-ovarian  abscess,  this  follows 
the  onset  of  the  symptoms. 

The  mass  formed  by  a  hsematosalpinx  and  hosmatocele  is  a  con- 
glomerate like  that  of  acute  salpingitis — substituting  blood  for  pus — 
and  in  neither  of  them  does  it  appear  at  once.  That  of  tubal  gesta- 
tion is,  however,  less  tender,  and  fever,  if  present,  is  a  late  develop- 
ment, whereas  in  salpingitis  it  is  one  of  the  earliest  signs.  The  patient 
undergoing  a  tubal  abortion  is  more  or  less  pallid,  and  gives  a  history 
of  fainting  attacks  with  the  spasms  of  pain,  while  the  size  of  the  mass- 


io62  THE   FALLOPIAN  TUBK 

felt  is  disproportionate  to  the  slight  inflammatory  signs.  In  sal- 
pingitis the  patient  is  flushed,  the  pain  is  and  has  been  continuous, 
and  fainting  has  not  occurred. 

A  twisted  ovarian  cyst  presents  as  a  tumour  from  the  first,  peculiarly 
defined  and  fluctuating,  and  there  is  no  preceding  amenorrhoea. 

A  tubal  abortion  is  often  mistaken  by  the  patient  for  abortion  of 
an  intra-uterine  gestation,  owing  to  the  pain,  the  blood  loss,  and  (when 
it  occurs)  the  passage  of  the  decidual  cast.  Examination,  by  revealing 
the  extra-uterine  mass,  should  point  to  the  nature  of  the  case,  but  the 
diagnosis  of  postabortional  salpingitis  is  sometimes  wrongly  made  in 
these  cases.  A  retroverted  gravid  uterus  when  incarcerated  and 
attempting  to  abort  may  be  mistaken  for  tubal  gestation  with  a  hsema- 
tocele,  and  vice  versa,  but  in  the  former  the  cervix  is  characteristically 
displaced  so  that  the  os  points  upwards  and  forwards. 

Intraligamentous  rupture  presents  general  features  resembling 
acute  pelvic  cellulitis,  but  the  absence  of  inflammatory  signs,  notwith- 
standing the  size  of  the  tumour,  with  the  blanching  and  the  history 
of  pregnancy,  should  distinguish  it. 

The  diagnosis  of  later  extra-uterine  gestation  is  usually  obvious, 
but  the  discrimination  from  intra-uterine  pregnancy  may  be  difficult 
if  the  secondary  sac  is  closely  fused  to  the  side  or  back  wall  of  the 
uterus. 

Treatment. — All  cases  up  to  the  sixth  month  should  be  imme- 
diately operated  upon.  Some  authorities  prefer  in  the  case  of  a  hsema- 
tocele  to  await  a  possible  natural  absorption.  Apart  from  its  involving 
an  invalidism  extending  over  two  or  three  months,  this  practice  has 
distinct  risks  :  (1)  Fresh  haemorrhage  may  occur,  for  the  trophoblast 
continues  to  grow  after  the  death  of  the  foetus  ;  (2)  the  gestation  may 
not  be  dead,  but  continuing  its  existence  in  a  secondary  sac  ;  (3)  the 
hematocele  may  suppurate. 

Operation. — In  acute  ruptures  the  greatest  expedition  must  be 
used,  the  patient  meanwhile  receiving  saline  venous  infusion.  The 
tube  should  be  pulled  up,  clamped  and  removed,  with  or  without 
the  ovary  according  to  the  condition  of  the  latter.  The  blood  in  the 
peritoneum  is  then  rapidly  cleared  out,  and  the  wound  closed.  In 
hematosalpinx  or  hematocele  presenting  less  violent  symptoms  the 
technique  is  that  of  the  operations  for  salpingitis  (see  p.  1054).  The 
ovary  should  always,  if  possible,  be  conserved.  The  opposite  tube  is 
found  occluded  in  many  cases,  but  salpingostomy  is  usually  feasible. 
Pelvic  drainage  is  not  generally  necessary  after  removing  the  blood 
clot,  but  if  definite  fever  has  been  present  a  small  tube  should  be 
introduced  through  the  lower  end  of  the  wound  for  a  day  or  two. 

If  a  broad-ligament  hematoma  is  found,  the  blood  should  be 
evacuated,  the  involved  tube  removed,  and  the  cavity  in  the  broad 


TUBAL    PREGN  WC*  :    I  RE  \  I  MEN  I 

tigamenl   obliterated  by  sutures,  or,  it  too  large  for  this  procedure, 
brought  to  th<'  Burface  and  drained, 

A  raptured  interstitial  gestation  may  !><•  treated  either  by  subtotal 
hysterectomy — or  better,    if   possible,  by   exsection  oi  the  tube  and 

cornu — and  repair  of  the  litems  by  sutures. 

Intraperitoneal  and  intraligamentous  gestation  up  to  tin-  sixth 
month  should  be  treated  by  removal  "i  the  sac.  In  the  firsl  case  the 
idhesions  to  the  omentum,  hack  of  the  uterus  and  broad  ligament, 
and  to  the  bowel,  will  have  to  lie  dealt  with.  Where  possible,  they 
■should  be  ligatured  or  clamped  before  division,  bu1  in  any  circumstances 
the  bleeding  will  he  very  free. 

In  the  second  case  the  haemorrhage  will  be  still  more  marked, 
the  whole  of  the  sac  being  commonly  placentous.  It  is  frequently  best 
in  these  circumstances  to  remove  the  body  of  the  uterus  as  well  as 
the  tube  on  the  involved  side.  In  either  event  the  operation  requires 
rapid  and  determined  execution. 

In  the  last  three  months  of  extra-uterine  pregnancy  operation  may 
'.be  necessitated  by  rupture  of  the  secondary  sac  or  separation  of  the 
extra-uterine  placenta,  but  the  ha'tnorrhage  involved  is  such  that  all 
authorities  agree  in  preferring  to  await,  if  possible,  the  death  of  the 
foetus  and  cessation  of  the  placental  circulation,  after  which  the 
removal  of  the  gestation  is  comparatively  easy.  If  compelled  to  inter- 
fere, the  surgeon  may — (1)  remove  the  foetus  alone  and  deliberately 
sequester  the  placenta  by  suturing  up  the  sac,  (2)  remove  the  foetus 
and  drain  the  sac  with  the  placenta  in  situ,  or  (3)  attempt  the  removal 
of  the  entire  sac  and  its  contents. 

Of  these  the  first  plan  is  the  best,  but  the  strictest  asepsis  must 
be  observed.  Drainage  of  the  sac  is  peculiarly  fatal,  the  patient  usually 
dying  of  sepsis  or  of  secondary  ha?morrhage.  The  third  undertaking 
is  very  formidable,  unless  the  placenta  is  mainly  attached  to  the 
omentum,  when  it  can  be  ligatured  off  successfully. 

I  ARCIXOMA 

This  is  a  rare  disease.  The  growth  assumes  a  papillary  form  which, 
distending  the  tube,  eventually  ruptures  it  into  the  peritoneal  cavity. 
There  is  strong  evidence  that  the  neoplasm  is  the  outcome  of  chronic 
salpingitis  in  which,  as  already  described,  there  is  a  marked  tendency 
for  the  epithelium  to  proliferate.  A  very  frequent  symptom  is  a  blood- 
stained watery  uterine  discharge,  originating  in  the  hydrosalpinx  pro- 
duced by  the  growth  occluding  the  abdominal  ostium  of  the  tube. 
In  many  cases  free  fluid  is  present  in  the  peritoneum.  Diagnosis  is 
difficult,  salpingitis  being  closely  simulated.  A  blood-stained  dis- 
charge with  ascites  is  suggestive.  Ablation  of  the  diseased  tube, 
with  the  uterus  and  the  rest  of  the  adnexa.  is  the  only  treatment. 


io64  THE    OVARY 

OTHER  NEW  GROWTHS 
Myomas  are  very  rare  in  the  tube.  Adenomyomas  have  been 
described.  They  consist  of  an  admixture  of  muscle  fibres  with  epi- 
thelial tubules  derived  from  the  lining  of  the  tube.  They  are  of 
inflammatory  origin.  Sarcoma  and  hydatid  cysts  in  tins  situation 
are  also  known. 

THE  OVARY 

ABSENCE    OF    THE    OVARY— ACCESSORY    OVARY 

One  or  both  ovaries  may  be  absent  or  infantile.  Occasionally  an 
accessory  ovary  outside  the  normal  one  may  be  present. 

PROLAPSE 

The  ovary  may  be  dragged  down  by  a  retro  verted  or  prolapsed 
uterus.  Not  infrequently  prolapse  occurs  with  the  uterus  in  normal 
position,  the  ligaments  being  relaxed  from  parturition  or  primary 
tissue  debility. 

Clinical  features. — The  principal  symptom  is  dyspareunia 
owing  to  the  tenderness  of  the  prolapsed  organ,  though  this  varies 
enormously  in  different  individuals.  Probably  some  cases  of  chronic 
"  ovarian  "  pain  are  due  to  this  displacement. 

Many  ovaries  clinically  tender  show  at  the  operation  filamentous 
adhesions  previously  unsuspected. 

Diagnosis. — The  normal  ovary  is  not  easily  felt,  because  there 
is  no  solid  background  against  which  to  feel  it.  Light  palpation  is 
necessary ;  much  force  pushes  the  organ  in  front  of  the  finger,  and 
defeats  its  end.     Rectal  examination  is  useful  in  these  cases. 

Treatment. — If  the  condition  gives  no  trouble  it  should,  of 
course,  be  let  alone.  When  neurasthenia  has  been  excluded,  and  the 
genuineness  and  ovarian  origin  of  the  symptoms  have  been  established, 
it  is  proper  to  attempt  relief. 

In  uncomplicated  ovarian  prolapse  the  ovarico-uterine  ligament 
should  be  shortened  after  the  method  first  described  by  me  in  1907. 
In  the  more  common  cases  associated  with  retroversion,  rectification 
of  the  uterine  displacement  and  the  use  of  a  pessary  may  succeed. 
This  failing,  ventro  -  suspension,  combined  with  shortening  of  the 
ovarian  ligaments,  is  a  proper  course  ;  or,  better  still,  intraperitoneal 
ligamentopexy  (p.  1006),  which  very  effectively  pulls  up  the  ovary. 

INFLAMMATION    (OOPHORITIS) 

Primary  ovarian  inflammation  is  rare,  though  it  frequently  arises 
secondarily  to  disease  of  the  tube,  as  previously  described.  Occasionally 
a  solitary  abscess  occurs,  probably  as  a  result  of  infection  of  a  recently 
dehisced  follicle  by  the  B.  coli  communis.     These  cases  are  very  ful- 


OVARIAN   CYSTS  1065 

minantj  no  symptoms  being  present  aa  a  rule  until  intraperitoneal 
rapture  of  the  abscess  initiates  a  violent  peritonitis  with  symptoms 
resembling  those  <>t  acute  perforation  <>i  an  abdominal  viscus.  They 
Bhould  1"'  treated  by  oophorectomy  and  peritoneal  drainage. 

In  the  condition  known  as  "fibrotic  oophoritis,"  or  "cirrhosis  of 
the  ovary,"  the  organ  is  found  much  reduoed  in  size,  very  bard,  and 
devoid  of  follicles.  The  stroma  shows  a  dense  fibrosis.  There  is,  how- 
ever, no  evidence  that  the  change  is  inflammatory.     It   is  met  with 

most  often  in  virgins,  and  is  sometimes  associated  with  a  peculiarly 
violent  form  of  dysmenorrheas  (see  p.  1082). 

OVARIAN   GESTATION 

The  cause  of  this  rare  event  is  unknown.  The  oosperm  embed- 
itself  in  the  wall  of  the  Graafian  follicle,  and  the  gestation  sac  thus 
formed  usually  ruptures  at  an  early  period  into  the  peritoneal  cavity. 
Cases  are,  however,  recorded  in  winch  an  apparently  ovarian  pregnancy 
endured  for  months,  or  even  went  nearly  to  term.  The  symptoms 
when  rupture  occurs  are  identical  with  those  of  ruptured  tubal  preg- 
namv,  and  the  treatment  is  similar  except  that  the  ovary  and  not 
the  tube  claims  the  operator's  attention  (see  p.  1062). 

NEW  GROWTHS   OF  THE  OVARY 

OVARIAN    CYSTS 

There  is  no  region  of  the  body  in  which  such  an  extraordinary 
diversity  of  new  growths  occurs  as  in  the  ovary,  and  their  elucidation 
constitutes  one  of  the  most  puzzling  and  most  interesting  problems 
in  pathology. 

The  ovary  is  developed,  like  the  testicle,  from  the  genital  ridge 
which  lies  immediately  inside  the  mesonephric  ridge. 

In  the  mesonephric  ridge  lie  the  mesonephric  tubules  and  the 
longitudinally-running  Wolffian  duct,  with  which  they  arc  connected. 
The  genital  ridge  is  very  early  covered  in  embryonic  life  with  a  special 
layer  of  cells  known  as  the  germinal  "  epithelium."  These  cells  are 
not,  however,  epithelial  nor  even  ectodermic  or  entodermic,  but  prob- 
ably represent  certain  elements  early  differentiated  from  the  rest 
of  the  cells  of  the  morula  for  reproductive  purposes.  In  the  develop- 
ment of  the  somatic  elements  of  the  body  a  progressive  differentiation 
of  the  cells  occurs,  first  into  ectoderm,  entoderm,  and  mesoderm,  and 
later  into  their  specialized  derivatives,  such  as  epithelium,  bone, 
muscle,  and  so  forth.  The  cells  of  the  germinal  epithelium,  however, 
unlike  those  of  the  rest  of  the  body,  claim  undifferentiated  descent  from 
the  primitive  blastomeres  into  which  the  dividing  oosperm  first  splits  ; 
from  them  develop  the  sexual  elements  of  the  new  individual,  in  the 


io66  THE    OVARY 

following  manner  :  Certain  of  the  cells  of  the  germinal  epithelium  in- 
grow  into  the  genital  ridge  in  a  series  of  prolongations  known  as  the 
medullary  cords.  In  the  female  these  cell  columns  become  the  egg 
tubes  of  Pfliiger,  and  break  up  into  a  series  of  cell  groups  known  as 
primitive  follicles  ;  from  them  the  ovum  and  the  cells  of  the  tunica 
granulosa  and  discus  proligerus  are  formed.  In  the  male  these  cell 
cords  develop  into  the  cells  lining  the  spermatogenic  tubules  ;  these 
tubules  are  subsequently  brought  into  continuity  with  the  mesonephric 
tubules  and  ducts,  and  therefore  into  communication  with  the  Wolffian 
duct,  which  now  acts  as  a  conduit  (vas  deferens)  for  conveyance  of 
their  secretion  (spermatozoa). 

In  the  female,  continuity  between  the  mesonephric  tubules  and 
collecting  ducts  and  the  ingrowths  from  the  germinal  epithelium  is 
never  established,  the  former  remaining,  together  with  the  Wolffian 
duct,  as  the  vestiges  in  the  mesosalpinx  and  ovarian  hilum  known  as 
the  paroophoron,  Kobelt's  tubules  (epoophoron),  and  Gartner's  duct 
respectively. 

The  Miillerian  ducts,  from  which  is  formed  the  female  genital 
canal,  are  developed  subsequently  to  the  Wolffian  ducts  and  outside 
them  in  the  mesonephros. 

In  the  earliest  stage  of  their  existence  each  communicates  with 
the  ccelom  by  three  apertures  which  eventually  fuse  to  form  the 
abdominal  ostium  of  the  Fallopian  tube.  Occasionally  this  fails,  and 
accessory  ostia  or  cysts  derived  from  them  are  found  in  adult  life. 

The  ovary,  therefore,  besides  being  in  immediate  relation  with 
several  vestigial  structures,  is  the  normal  seat  of  undifferentiated 
embryonic  cell  seclusions.  The  enormous  growth  potentialities  of 
these  cells,  as  far  as  the  ova  are  concerned,  are  held  in  abeyance  by 
the  occurrence  in  them  of  a  peculiar  form  of  karyokinetic  division 
(maiotic  mitosis)  wThereby  the  number  of  chromosomes  contained  in 
each  cell  is  reduced  to  one-half  of  those  in  a  somatic  cell. 

Should  this  process  fail  to  occur,  the  possibility  of  a  tumour  by 
asexual  cell  division  of  an  ovum  must  be  admitted.  The  cells  of  the 
granulosa,  likewise  derived  from  the  germinal  epithelium,  are  possibly 
also  the  seat  of  initiation  of  such  teratomatous  formations,  whilst  others 
may  be  derived  from  sequestered  cells  aberrant  from  the  primitive  egg 
tubes,  or  subsequent  ingrowths  from  the  germinal  epithelium.  Such 
an  hypothesis  best  explains  the  frequency  of  teratomatous  tumours 
in  the  sexual  glands  and  the  fact  that  the  ovary,  though  it  contains 
developmentally  neither  ectodermic  nor  entodermic  derivatives,  yet 
produces  enormous  tumours  chiefly  composed  of  epithelium. 

Cysts  in  the  ovarian  region  may  be  divided  into  four  groups  : 
(1)  cysts  of  the  ovary  proper,  (2)  cysts  of  the  ovarian  hilum,  (3)  cysts 
of  the  broad  ligament,  and  (4)  cysts  of  the  tube. 


OVARIAN    CYSTS  1067 

1.  Cysts  of  the  ovary  (oophoronic  cysts).  All  ovarian 
cysts  are  a1  firsl  pedunculated  like  the  organ  itself.  Their  walls 
ire  composed  of  Btretched  ovarian  tissue,  and  have  a  characteristic 
yearly-white  or   bluish   tint,   according    to  their  thickness    and    the 

character  of  the  underlying  contents. 

Follicular  cysts — The  simplesl  species  arc  those  derived  by 
distension  of  the  Graafian  follicle  in  various  stages  of  its  existence. 
There  are  three  varieties  of  follicular  cyst:  (a)  the  simple  follicular 
cyst.  (/>)  the  follicular  blood  cyst,  and  (c)  the  lutein  cyst. 

(a)  Simple  follicular  cysts.  These  may  be  single  or  multiple.  In 
the  former  case  the  whole  ovary  is  transformed  into  a  pedunculated, 
thin-walled,  whitish-blue  cyst,  containing  a  thin,  straw-coloured  fluid. 
In  the  smaller  cysts  the  wall  is  lined  inside  with  a  short  columnar 
epithelium,  but  in  the  larger  ones  this  is  flattened  out  or  actually 
disappears.  Multiple  follicular  cyst  formation  is  usually  associated 
with  chronic  salpingo-oophoritis,  the  peripheral  sclerosis  and  adhesions 
preventing  the  dehiscence  of  the  follicles. 

(b)  Follicular  blood  cysts. — After  dehiscence  of  the  follicle,  bleeding 
normally  occurs  into  it,  producing  the  <;  corpus  hsemorrhagicum."  This 
haemorrhage  may  occasionally  be  excessive  and  result  in  the  formation 
of  a  blood  cyst  whose  walls  represent  the  stretched  and  thinned  tissue 
of  the  ovary.  These  cysts  have  a  very  characteristic  dark-red  colour 
and  are  liable  to  rupture,  with  severe  intraperitoneal  bleeding. 

(c)  Lutein  cysts. — Cystic  degeneration  of  the  corpus  lutein  has  only 
been  described  within  recent  years.  The  cysts  are  usually  small,  and 
only  distinguishable  from  the  simple  follicular  cyst  by  microscopical 
discovery  of  a  layer  of  lutein  cells  lining  the  cavity.  Their  significance 
is  unknown,  but  they  have  been  found  with  such  unusual  frequency 
in  association  with  chorion-epithelioma  that  some  general  etiological 
connexion  is  strongly  suggested. 

Ovarian  cyst-adenomas. — The  majority  of  large  ovarian  cysts 
belong  to  this  group  (Fig.  615).  They  are  multilocular,  though  one 
loculus  may  predominate  in  size.  The  smaller  loculi  are  lined  with  a 
tall  columnar  muciniferous  epithelium  (Fig.  616),  but  in  the  larger 
ones  the  cells  become  flattened.  The  content  of  the  cyst  is  mucin, 
more  viscid  in  the  smaller  loculi  and  less  so  in  the  larger.  It  may  be 
transparent,  whitish-yellow,  or  green,  or  brown  from  blood-staining,  in 
different  cases.  When  large,  these  cysts  are  usually  more  or  less 
adherent  to  the  omentum  or  bowel. 

It  has  been  suggested  that  cysts  of  this  group  are  derived  by 
proliferation  of  certain  of  the  cells  of  the  follicle  from  sequestered 
aberrant  remnants  of  the  primitive  egg  tubes,  or  from  subsequent 
ingrowths  of  the  germinal  epithelium.  They  may  occur  at  any  age 
from  puberty  onwards,  but  are  commonest  after  30. 


io68 


THE    OVARY 


Teratomatous  cysts  (dermoid  cysts;  embryomas). — The 
fact  that  the  ovary  is  the  normal  seat  of  undifferentiated  embryonic 
cell  seclusions  probably  explains  the  extraordinary  diversity  of  growths 
originating  in  that  organ.  If  so,  many  ovarian  tumours  not  always 
considered  as  teratomatous  might  be  included  in  this  category  (e.g. 
ovarian  cyst-adenomas).  Setting  aside  these  more  debatable  classes, 
there  remain  two  whose  embryonic  origin  is  admitted  by  all,  viz.  the 
simple  dermoid  cyst  and  the  multiloeular  cyst-embryoma. 

Of  these  the  simple  dermoid  is  much  the  commoner.     It  is  unilocular 


Multiloeular  ovarian   cyst- adenoma. 


as  a  rule,  and  its  wall  is  formed  of  stretched  ovarian  tissue  (Fig.r617). 
At  one  part  of  it  the  "  embryonic  rudiment  "  presents  as  an  irregular 
projection  into  the  cavity,  covered  by  a  coarse  skin  containing  a  large 
number  of  sebaceous  follicles.  Many  hairs  grow  from  this  area,  and 
projecting  from  it  or  embedded  in  it  may  be  found  one  or  several 
teeth  more  or  less  well  formed,  and  set  into  an  irregular  plate  of  bone 
(Fig.  618).  Microscopical  investigation  of  the  embryonic  area,  besides 
showing  a  definite  skin  (Fig.  619),  may  reveal  other  tissues  such  as 
cartilage,  muscle  bundles,  or  nerves.  The  rest  of  the  cyst  is  usually 
lined  with  a  flattened  or  definitely  cubical  epithelium.  It  contains  a 
yellow  fat,  liquid  when  it  is  first  removed  from  the  body,  but  rapidly 
hardening  afterwards,  and  then  resembling  cocoa  butter.  Embedded 
in  it  is  a  quantity  of  coarse  reddish  or  brownish  hair. 


OVARIAN   CYSTS 


1 1  if.- 1 


.  % 


•  v 


?.y,v_  k 


The  multilocular  cyst-erribryoma  is  much  rarer.  It  consists  in  large 
part  of  solid  masses  intermixed  with  cavities  of  different  sizes,  whose 
contents  vary  from  typical  dermoid  material  to  mucus  and  clear  serum. 
Those  containing  fat  are  lined  with  a  perfect  skin,  coated  with  vernix 
caseosa  like  that  of  a  new-born  infant.  Others  present  a  mucous 
membrane  exactly  similar  to  that  of  normal  bowel;  whilst  in 
columnar  ciliated  epithelium  is  found  like  that  of  the  trachea.  Micro- 
scopically, every  variety  of  tissue  characterizing  the  human  body  is 
found  in  irregular  arrangement  (Fig.  620),  and  in  exceptional  ex- 
amples well-formed 
portions  of  the 
lower  part  of  a 
foetus  may  be  pre- 
sent. 

It  is  a  remark- 
able fact  that  endo- 
genous teratomas, 
whether  occurring 
in  the  ovary  or 
elsewhere,  rarely  de- 
velop before  puber- 
ty, the  commonest 
age  at  which  they 
are  met  with  being 
between  20  and  30. 

2.  Cysts  of  the 
ovarian  hilum 
(paroophoronic 
cysts) .  —  The  cysts 
that  occasionally 
develop   in  the 

hilum  of  the  ovary  are  probably  derived  from  those  remnants  of  the 
mesonephric  tubules  known  as  the  paroophoron  and  from  some  of  the 
earlier  ingrowths  of  the  germinal  epithelium  (rete  cords).  They  may 
be  unilocular  or  multilocular  ;  they  grow  into  the  ovary,  wdiich  lies 
on  their  posterior  surface,  and  burrow  into  the  broad  ligament  in  front. 
They  are  particularly  prone  to  develop  intracystic  papillomas,  in  virtue 
of  which  they  become  more  or  less  malignant  (see  Papuliferous  Cysts, 
p.  1072).     They  are  commonest  between  the  ages  of  30  and  50. 

3.  Broad-ligament  cysts. — A  cyst  growing  in  the  broad 
ligament  is  covered  by  its  peritoneal  layers,  and  as  it  invades  the  meso- 
salpinx has  the  tube  stretched  across  it  (Fig.  621).  These  features 
are  characteristic.  Cysts  developing  in  the  outer  third  of  the  meso- 
salpinx are   pedunculated ;   but  those  arising  in   any  other   position 


Fig.  610. — Ovarian  cyst-adenoma,  the  loculi  lined 
'with  a  tall  columnar  muciniferous  epithelium. 


TIM.    OVARY 


are   always   sessile.     The  ovary  is  at  first   quite   separate  from  the 
cyst,  but  when  the  latter  attains  a  large  size  this  organ  may  become 

incorporated  with   its 
posterior  wall. 

Broad-ligament 
cysts  are  usually  uni- 
locular, and  contain 
a  thin  straw-coloured 
fluid. 

As  regards  their 
origin,  they  may  be 
divided  into  two 
classes  —  («)  parova- 
rian (epoophoronic), 
and  (b)  inflamma- 
tory. 

(a)  Parovarian 
cysts. — Distension  of 
the  vestigial  ducts  of 
the  parovarium  pro- 
duces cysts  originat- 
ing  in  the  mesosal- 
pinx. AVhen  developed 
from  one  of  the  outer 
group  (Kobelt's  tubes)  the  cyst  is  stalked  and  small.  Cysts  of  the  outer 
segment  of  Gartner's  duct  have  a  peduncle  formed  of  the  tube  and  the 

inner  portion  of  the 
mesosalpinx,  but  those 
arising  nearer  the 
uterus  have  no  pedi- 
cle and  burrow  down- 
wards into  the  lower 
part  of  the  broad  li- 
gament. Parovarian 
cysts  have  a  lining  of 
short  cubical  epithe- 
lium like  that  of  the 
tubules  from  which 
they  spring  (Fig.  622). 
Cilia  have  been  de- 
scribed, but  these,  if 
found,  probably  indi- 
cate a  Mullerian  origin.  Parovarian  cysts  contain  a  thin  serous  fluid. 
They  are   commonest  between  30  and  40  years  of  age. 


-Unilocular  teratomatous  cyst 
(dermoid  cyst). 


Fig.  61S. — Dermoid   cyst,  opened   to  show  the 
fcetal  rudiment  with  two  well-formed  teeth. 


OV  \KI  \\    CYSTS 


i"7  i 


(l>)  Inflamma- 
tory broad-liga- 
ment cysts. 
These  cysts,  origi- 
nating more  parti- 
cularly in  the 
deeper  pari  of  the 
broad  ligament, 
are  produced  by 
lymphatic  blockage 
(lymphatic  cysts), 
and  may  then  be 
multilocular,  or 
i  h  e  y  m  a  y  b  e 
formed  by  encysl  - 
nii'iit  of  a  broad- 
ligament  abscess 
with  gradual  dis- 
integration of  the 
pus  until  a  thin 
grumous  fluid  re- 
sults. 

4.     Tubal 
cysts — Accessory 
fimbriated  extremi- 
ties of    the  Fallo- 
pian tube  are  not 
uncommonly  found 
as  short  "  anemone- 
like "    processes, 
and   represent    the 
permanence  of  the 
primitive     coelomic 
ostia,      of      which 
there     are      three. 
Sampson    Handler 
first     pointed    out 
that   certain    cysts 
arising      in       this 
situation    are     de- 
veloped from  such 
-vs.    They  are 
unilocular,  present,  , 
when     small,     a 


oo 


\ 


f 


Fig.  619. — Wall  of  dermoid  cyst. 

s  a  well-formed  skin  containing  hair-follicles, sebaceous 

and  sweat-glands,   and   unstriped  muscle  fil 


Fig.  620. — Cyst-embryoma. 

\'arious  tissues   arc  seen  embedded,    in  which    may  be  noted' 

a  mass  of  cartilage  and  several  spaces  lined  with  different  types 

of  epithelium. 


1072 


THE   OVARY 


ciliated  epithelium  similar  to  that  of  the  tube,  and  contain  rudimen- 
tary plicae.       Small  cysts  are  also  found  along  the  line  of  the  tubo- 


Fig.  621. — Parovarian  cyst.     The  tube  runs  over  it,  and  the  ovary 
is  not  connected  with  it. 

ovarian  fimbria.     Their  origin  is  debatable,  but  is  probably  derived 
from  the  vestiges  of  the  anterior  end  of  the  Wolffian  duct. 

Papuliferous  and  malignant  ovarian  cysts. — Int ra- 
cy stic  papillomas 
may  develop  in  any 
cyst  lined  with  epi- 
thelium, and  may, 
therefore,  complicate 
any  of  the  cysts 
just  described.  The 
nature  of  the  papil- 
lomatous growth 
varies.  Short  round- 
topped  elevations 
formed  by  fibrous 
excrescence  from  the 
cyst  wall  are  often 
seen.  Soft  villous 
papillomas  are  par- 
ticularly, but  not 
exclusively,  asso- 
ciated with  paroo- 
phoronic  cysts. 
They    present    exu- 


Fig.  622. — Wall  of  a  parovarian  cyst  lined  with 
several  layers  of  cubical  epithelial  cells. 


OVARIAN    CYSTS 


io73 


beranl  masses  growing  in  tufis  which  after  a  time  burrow  through 
the  oysi  wall  and  sproul  on  its  outer  surface.  When  large  they 
entirely  till  t  he  cyst 
oavity  and  eventu- 
ally cause  rupture. 
They  then  become 
rapidly  diffused  and 
grafted     over     the 

whole  of  t  he  surface 

of  the  peritoneum, 
w  h  i  c  li  m ay  be 
studded  with  thou- 

sands  of  little 
secondary  growths. 

This  change  is  as- 
sociated with  rapid 
effusion  of  peri- 
toneal fluid. 

In  microscopi- 
cal structure  they 
vary.  The  more 
innocent  present  a 
single  layer  of 
columnar  epithe- 
lium (Fig.  623), 
but  in  others  these 
cells  are  massively 
arranged  in  many 
layers  (Fig.  624). 
These  latter  are 
frankly  malignant, 
and  rapidly  recur 
after  removal,  but 
secondary  nodules 
of  the  single- 
layered  type  may 
spontaneously  dis- 
appear after  the 
removal  of  the 
primary  growth. 

Many  other 

forms  of  malignant 

degeneration     may 

occur    in     ovarian 

3q 


Fig.  623. — Benign  papilliferous  cyst. 

The  papillomas  are  covered  with  a  single  layer  of  epithelium. 


Fig.  624. — Malignant  papilliferous  cyst. 

Large    masses    of    epithelium    cover    the    papillomatous   out- 
growths and  infiltrate  the  cyst   wall. 


io74  THE   OVARY 

cysts.  The  cyst-adenomas  not  infrequently  contain  solid  masses 
having  the  structure  of  spheroidal-  or  columnar  -  celled  carcinoma. 
Squamous-celled  carcinoma  has  been  recorded  arising  from  the  skin- 
covered  surface  of  a  dermoid  cyst,  whilst  the  cystic  embryoma  may 
become  malignant  in  virtue  of  any  or  all  of  the  tissues  contained  in 
it.  Thus,  chorion-epithelioma  and  various  forms  of  carcinoma  and 
sarcoma  may  all  arise  in  it,  or  the  whole  cyst  may  assume  malig- 
nancy, the  metastases  presenting  the  same  multiform  characters  as 
the  primary  growth. 

A  peculiar  form  of  colloidal  growth  arises  in  some  multilocular 
cysts.  The  growth  perforates  the  cyst  wall  and,  becoming  grafted  on 
the  peritoneum,  produces  enormous  quantities  of  material  like  painter's 
size,  which  gradually  distends  the  peritoneal  cavity.  Evacuation  of 
the  contents  is  followed  by  reaccumulation,  and  cases  are  on  record 
where  this  procedure  has  been  repeated  over  several  years.  The  basis 
of  the  growth  is  a  colloid  tissue  containing  few  cells.  Sarcoma  of 
varying  types  may  originate  in  a  cyst  wall.  Secondary  deposits  of 
carcinoma  in  the  ovary  are  very  common,  and  are  often  partially  cystic 
owing  to  the  inclusion  of  distended  follicles  in  the  growth.  They 
are  nearly  always  bilateral,  and  are  usually  secondary  to  malignant 
disease  of  the  intestine  or  gall-bladder. 

Symptoms. — The  symptoms  of  ovarian  cysts  may  be  divided 
into  those  due  to  (1)  bulk,  (2)  pressure,  (3)  torsion,  (4)  inflammation, 
(5)  rupture,  (6)  malignant  degeneration. 

Bulk. — The  rate  of  growth  of  an  ovarian  cyst  varies.  Dermoids 
may  grow  very  slowly.  Cyst -adenomas  attain  a  fair  size  in  two  years. 
Malignant  cysts  may  reach  a  great  bulk  in  a  few  months  ;  while  cer- 
tain accidental  occurrences  such  as  torsion  or  inflammation  produce 
very  rapid  increase  in  size. 

Cysts  weighing  over  100  lb.  have  not  infrequently  been  recorded. 
In  the  absence  of  complications,  ovarian  cysts  do  not  at  first  affect 
the  general  health,  but  later  the  increasing  enlargement  of  the  abdomen 
is  accompanied  by  the  so-called  "  ovarian  cachexia,"  characterized  by 
extreme  emaciation  and  an  earthy  or  definitely  pigmented  colour  of 
the  skin. 

Pressure. — Impaction  in  the  pelvis  may  occur,  with  retention  of 
urine,  partial  intestinal  obstruction,  and  great  pain  ;  but  this  is  a  much 
less  common  event  than  with  myomas.  Enormous  tumours  interfere 
with  respiration  and  the  intestinal  functions,  and  may  produce  signs 
due  to  pressure  on  the  vena  cava. 

Torsion. — Torsion  of  the  pedicle  is  the  commonest  complication 
of  an  ovarian  cyst.  It  may  follow  a  violent  effort  or  the  emptying 
of  a  pregnant  uterus,  but  often  no  cause  is  apparent.  The  first  twist 
is  usually  small,  but  sufficient  to  obstruct  the  venous  return  through 


OVARIAN  CYSTS:   SYMPTOMS  1075 

the  pedicle.  As  a  result,  the  cysl  wall  and  the  pedicle  distal  do  the 
1  wist  become  oedematous  and  swell.  This  occasions  a  blither  twisting, 
with  increased  oedema;  and  so  on,  until  the  blood-flo^  through  the 
pedicle  may  be  entirely  arrested.  The  cysl  becomes  purple  or  Mack 
Erom  venous  congestion,  and  its  contents  are  rapidly  augmented  by 
the  effusion  of  serum  and  blood  into  the  cavity.  Occasionally  large 
quantities  of  blood  may  be  thus  poured  out.  The  necrol  i<-  wall  indu< 
peritonitis  around  it,  with  the  formation  of  adhesions  through  which 
the  circulation  may  be  re-established.  Spontaneous  recovery  some- 
times takes  place,  the  necrotic  cyst  becoming  sequestered  by  universal 
adhesions.  More  commonly,  however,  general  peritonitis  is  set  up, 
to  which  the  patient  would  succumb  if  untreated. 

A  twisted  cyst  rapidly  increases  in  size  and  becomes  very  tense 
and  tender.  It  usually  crosses  the  middle  line  to  the  opposite  side, 
becomes  markedly  unilateral,  and  pulls  the  uterus  in  the  same  direction 
by  the  tension  of  the  pedicle.  The  pain  is  at  first  spasmodic,  the  exacer- 
bations coinciding  with  the  successive  twists  ;  later  on,  as  peritonitis 
is  set  up,  the  distress  becomes  continuous,  and  vomiting  and  flatulent 
distension  appear. 

Rupture. — Spontaneous  rupture  is  most  commonly  seen  with 
papuliferous  cysts.  The  abdomen  rapidly  fills  up  with  ascitic  fluid, 
and  some  tenderness  and  pain  may  be  present,  owing  to  the  secondary 
peritoneal  implantations  ;  these  may  be  felt,  on  deep  palpation,  as 
irregular  masses.  The  patient  wastes,  and  often  shows  slight  con- 
tinuous fever. 

Cyst-adenomas  rarely  rupture,  owing  to  the  early  formation  of 
adhesions.  The  escape  of  the  mucous  contents  sets  up  a  subacute 
peritonitis  with  pain  and  tenderness.  Ruptured  colloidal  cysts  present 
the  same  clinical  picture  as  ruptured  papuliferous  cysts,  but  the  dis- 
tension and  general  deterioration  are  slower.  The  bursting  of  an 
ovarian  blood  cyst  or  profuse  haemorrhage  from  a  corpus  hsemor- 
rhagicum  almost  exactly  simulates  a  ruptured  tubal  gestation,  but  a 
history  of  preceding  amenorrhoea  is  absent.  Thin-walled  follicular 
cysts  may  rupture  spontaneously,  or  in  the  course  of  examination.  The 
fluid  is  non-irritant  and  is  soon  absorbed,  but  the  cyst  re-forms  after 
a  while.  Very  rarely  the  sudden  effusion  of  blood  into  the  cavity  of  a 
twisted  cyst  has  caused  the  wall  to  rupture. 

Malignant  degeneration. — Malignant  ovarian  cysts  give  rise 
to  a  fixed  mass,  ascites,  and  rapid  emaciation.  Later,  metastatic 
masses  are  felt  in  the  omentum,  parietes,  and  liver.  These  secondary 
growths,  especially  those  in  the  omentum,  are  often  the  first  to 
attract  attention.  They  have  the  bossy  feel  of  a  number  of  rounded 
nodules  partially  fused  together,  and  when  omental  may  be  very 
movable. 


io;6  THE    OVARY 

Diagnosis. — If  the  uterus  cannot  be  separated  from  the  mass, 
absolute  distinction  from  a  myoma  may  be  impossible.  Marked 
fluctuation  and  the  presence  of  a  fluid  thrill  are  in  favour  of  ovarian 
origin,  but  a  cystic  myoma  may  present  the  same  signs.  Many  ovarian 
tumours  do  not  fluctuate,  especially  dermoids  and  multilocular  cyst- 
adenomas,  while  cyst-embryomas  and  malignant  cysts  are  largely  solid 
in  composition.  A  vascular  murmur  over  the  tumour  strongly  suggests 
a  uterine  origin.  The  history  of  menorrhagia  usual  with  a  myoma 
is  rare  with  an  ovarian  cyst,  unless  complicated  by  one  of  these 
tumours. 

Ovarian  cysts  usually  grow  much  more  quickly  than  myomas, 
while  tumours  first  discovered  under  30  or  above  55  years  of  age  are 
probably  ovarian.  The  frequency  with  which  myomas  and  ovarian 
cysts  coexist  must  not  be  forgotten. 

Pregnancy  is  distinguished  from  an  ovarian  cyst  by  the  enlargement 
being  uterine,  by  its  usually  greater  rate  of  growth,  by  the  presence 
over  it  of  a  vascular  murmur  and  signs  of  foetal  life,  and  by  the 
corresponding  period  of  amenorrhcea. 

Ovarian  cysts  only  cause  amenorrhcea  when  they  are  bilateral  and 
have  totally  destroyed  all  normal  ovarian  tissue.  This  is  chiefly  seen 
in  malignant  cysts,  in  which  the  rate  of  enlargement  may  be  rapid  and 
pregnancy  more  particularly  simulated. 

A  distended  bladder  is  immediately  distinguished  on  passage 
of  the  catheter — a  precaution  never  to  be  omitted  in  cases  of 
doubt. 

Ascites  shows  signs  of  movable  fluid  and  produces  a  different 
shape  of  the  abdomen,  the  loins  particularly  being  bulged  ;  moreover, 
the  front  of  the  abdomen  is  resonant  and  the  flanks  are  dull,  the 
reverse  being  the  case  with  a  cyst.  Encysted  peritoneal  fluid,  as  seen 
in  some  forms  of  tubercular  peritonitis  or  in  "  encysted  serous  peri- 
metritis," may  closely  simulate  an  ovarian  cyst,  but  the  swelling  is 
fixed  and  the  percussion  note  frequently  partly  resonant  owing  to 
adherent  bowel  lying  over  it.  A  large  hydrosalpinx  may  be  indis- 
tinguishable from  an  ovarian  cyst,  whilst  many  tense  broad-ligament 
cysts  are  mistaken  for  broad-ligament  myoma.. 

Retroperitoneal  cysts  of  various  kinds  closely  simulate  ovarian 
cysts,  but  their  front  is  resonant,  and  most  of  them  (hydronephrosis, 
pancreatic  cysts)  have  no  connexion  with  the  pelvis. 

The  diagnosis  of  torsion  of  an  ovarian  cyst  from  rupture  of  tubal 
gestation  and  acute  salpingitis  is  discussed  under  the  latter  two  headings. 
The  most  striking  feature  is  the  presence  of  a  large  cystic  tumour  from 
the  very  outset  of  the  symptoms. 

A  ruptured  papuliferous  cyst  or  other  form  of  cyst  with  ascites 
mav  be  mistaken  for  terminal  hepatic  cirrhosis  or  acute  tuberculous 


OVARIAN   CYSTS:    TREATMENT  i<>77 

peritonitis.  In  most  cases  a  pelvic  tumour  can  be  felt,  which  excludes 
the  hepal  ic  condition.  In  1  aberculous  peritonitis,  bowever,  a  mass  may 
also  be  fell  per  vaginam,  but  in  this  condition  there  is  usually  much 
more  fever  I  han  in  rupl  ured  cyst. 

In  all  cases  of  doubl  t  be  peritoneal  cavity  should  be  eXplor<  d.    Many 

a  woman  lias  been  tapped  repeatedly  for  an  ascites  due  to  an  unsus- 
pected papuliferous  cyst. 

An  inflamed  cyst  simulates  acute  pyosalpinx,  bul  the  mass  Is  from 

the  commencement    more  circumscribed  and  defined. 

Treatment. — All  ovarian  cysts  should  be  removed  as  soon  as 
possible,  through  an  abdominal  incision. 

A  pedunculated  cyst  is  treated  by  excision,  the  pedicle  being  first 
(lamped.  Ligation  of  the  pedicle  should  be  carried  out  in  sections. 
to  minimize  the  risk  of  the  ligatures  slipping.  Large  unilocular  cysts 
with  clear  fluid  contents  should  be  tapped  before  removal,  but  all 
others  should  be  excised  whole  for  fear  of  escape  into  the  peritoneum 
of  irritant  or  infected  matter  or  transplantable  tumour  cells.  Multi- 
locular  cysts  cannot  be  satisfactorily  tapped.  Adhesions  to  the  cyst 
wall  should  be  separated  as  far  as  possible  before  tapping  if  this  course 
be  followed. 

Sessile  broad-ligament  cysts  are  to  be  treated  by  enucleation  from 
their  peritoneal  investment.  This  is  often  easy,  the  gap  in  the  broad 
ligament  being  subsequently  closed  with  sutures.  In  other  cases  only 
part  of  the  cyst  can  be  so  removed  ;  the  remainder  should  be  brought 
up  to  the  abdominal  wound  and  drained. 

The  excision  of  a  broad-ligament  cyst  is  sometimes  facilitated  by 
removal  of  the  uterus.  Where  the  cyst  has  burrowed  deeply  its  removal 
may  be  a  very  difficult  operation. 

Ovarian  cysts  are  sometimes  universally  adherent.  In  many 
instances  the  cyst  wall  can  be  readily  shelled  out,  but  in  others  this 
is  impossible  without  serious  damage  to  the  intestines  and  mesentery. 
In  this  case  the  best  course  is  to  empty  the  cyst  and  then  suture  up 
the  aperture,  leaving  the  patient  to  be  tapped  subsequently  as  the 
fluid  reaccumulates. 

Cysts  of  the  ovary  or  ovarian  hilum  burrowing  into  the  broad 
ligament  are  treated  by  enucleation,  like  actual  broad-ligament  cysts. 

Malignant  cysts  should  be  removed  whenever  possible  ;  but  great 
judgment  must  be  exercised,  for  the  bleeding  in  these  cases  may  lie 
so  free  that,  once  started,  the  operator  may  find  it  impossible  to 
go  back. 

The  operation  of  ovariotomy  has  nowadays  a  mortality  greater 
than  that  of  simple  hysterectomy.  This  is  on  account  of  the  large  pro- 
portion of  malignant  cases  dealt  with,  in  which  the  death-rate  is  high. 
Excluding  these,  the  average  risk  is  probably  2  per  cent. 


1078  THE   OVARY 

FIBROMA 

Fibrous  tumours,  many  of  them  of  large  size,  are  occasionally  met 
with  in  the  ovary.  They  arise  as  (a)  a  diffuse  fibrous  overgrowth  of  the 
whole  of  the  ovarian  stroma,  (b)  a  local  encapsuled  mass,  or  (c)  a  pedun- 
culated outgrowth  from  the  surface  of  the  ovary.  They  are  most 
frequently  met  with  between  the  ages  of  30  and  50.  In  structure  they 
are  pure  fibromas,  and  show  much  less  tendency  to  degeneration  than 
is  the  case  with  myomas.  They  take  about  two  years  to  attain  the 
size  of  a  cricket-ball.  They  produce  symptoms  of  pressure  like  a 
pedunculated  subserous  myoma.  In  most  recorded  cases  free  fluid 
has  been  present  in  the  abdominal  cavity,  a  circumstance  that  caused 
them  to  be  regarded  as  sarcomas  in  the  past.  It  is  impossible  to 
distinguish  absolutely  a  fibroma  from  a  subserous  myoma  with  a  long 
pedicle,  before  the  abdomen  is  opened.  The  absence  of  menorrhagia 
and  the  detection  of  signs  of  free  peritoneal  fluid  would  suggest  a 
fibroma.  The  tumour  must  be  removed,  the  steps  of  the  operation 
being  those  already  described  under  Ovarian  Cysts  (p.  1077). 

ADENOMA 

Solid  adenomas  in  the  ovary  are  rare.  Their  nature  can  only  be 
ascertained  by  microscopical  examination,  when  a  series  of  regular 
glandular  spaces  lying  in  a  fibro-cellular  stroma  is  revealed.  Like 
fibromas,  adenomas  cause  some  ascites  and  produce  pressure  symptoms. 
They  must  be  removed  as  soon  as  possible,  and  if  doubt  as  to  the 
innocent  nature  of  the  growth  exists  the  uterus  should  be  removed 
also. 

PAPILLOMA 

A  rare  villous  type  of  papilloma  originating  in  the  germinal  epithe- 
lium, and  producing  secondary  peritoneal  growths  and  ascites,  is 
known.  Removal  of  the  primary  growth  is  followed  in  some  cases 
by  spontaneous  disappearance  of  the  secondary  growths  in  the  peri- 
toneum. 

SARCOMA 

Many  different  types  of  primary  sarcoma  occur  in  the  ovary,  the 
round-celled  variety  being  the  commonest.  All  ages  are  attacked, 
and  cases  have  been  recorded  even  in  infancy.  In  children  and  young 
persons  the  growth  is  often  bilateral,  but  in  older  patients  only  one 
side  is  usually  affected. 

Secondary  sarcoma  of  the  ovary  is  uncommon,  except  in  the 
melanotic  variety,  in  which  large  bilateral  tumours  may  be  found 
post  mortem. 

Ascites  is  early  noticed,  the  tumour  is  fixed  and  grows  rapidly, 
and  the  patient  wastes.     The  diagnosis  of  malignancy  is  usually  not 


OVARIAN   CARCINOMA 


1079 


difficult,  but  the  occurrence  of  ascites  with  simple  fibromas  must 
be  remembered.  The  histological  nature  of  the  growth  can  only  be 
determined  after  removal.  The  uterus  and  both  appendages  musl 
be  totally   extirpated. 

CARCINOMA 

Primary  growths  exhibit  various  characters  in  difierenl  eases,  the 
tubular  columnar-celled  type  being  that  most  frequently  met  with. 

Secondary  carcinoma  is  much  more  common,  and  is  especially 
associated  with  carcinoma  of  the  stomach  or  some  part  of  the  intestines. 


Fig.  625. — Uterus  with    bilateral  malignant  ovarian  tumours. 


In  terminal  carcinoma  of  the  breast,  surface  metastases  on  the  ovary 
are  often  found,  as  shown  by  Handley.  Secondary  carcinomatous 
tumours  are  nearly  always  bilateral,  and  are  usually  partly  cystic  from 
the  inclusion  of  dropsical  follicles  in  the  growth  (Fig.  625). 

Primary  carcinoma  exhibits  the  same  general  symptoms  and  signs 
as  primary  sarcoma  (see  p.  1078).  Secondary  carcinomatous  tumours 
attain  a  large  size,  and,  as  pointed  out  by  Bland-Sutton,  their  metas- 
tatic origin  may  be  overlooked. 

Immediate  removal,  together  with  the  uterus  and  the  rest  of  the 
appendages,  is  the  only  course. 

Jf  the  condition  is  bilateral,  a  very  careful  search  should  be  made 
for  a  primary  growth  in  the  abdomen  elsewhere. 


io8o  THE   PELVIC   PERITONEUM 

THE  PELVIC  PERITONEUM  AND  CELLULAR 

TISSUE 

PELVIC    PERITONITIS    (PERIMETRITIS) 

Pelvic  peritonitis  is  always  secondary  to  inflammation  of  some  of 
the  pelvic  organs.  In  the  vast  proportion  of  cases  salpingitis  is  the 
primary  cause,  but  occasionally  this  role  is  played  by  a  solitary  ovarian 
abscess,  an  infected  ovarian  or  uterine  tumour,  a  hsematocele,  or  an 
inflamed  appendix  situated  in  the  pelvis. 

The  symptoms  and  treatment  of  pelvic  peritonitis,  therefore,  are 
those  of  the  lesion  to  which  it  is  secondary. 

PELVIC    CELLULITIS    (PARAMETRITIS) 

Infection  of  the  pelvic  cellular  tissue  is  usually  secondary  to  some 
lesion  of  the  vagina,  of  the  cervix  or  the  body  of  the  uterus.  Thus, 
it  is  usually  seen  after  labour  or  after  operations  upon  the  genital 
canal.  Occasionally  it  is  primary,  as  in  cases  of  inflamed  broad- 
ligament  cyst,  or  suppuration  round  an  intraligamentous  lithopsedion. 

In  anterior  cellulitis  the  inflammatory  mass  is  situated  between  the 
cervix  and  vagina  and  the  posterior  wall  and  base  of  the  bladder.  In 
lateral  cellulitis  the  infection  usually  follows  the  lymphatic  tract  that 
accompanies  the  uterine  artery  and  vein,  and  thus  involves  the  base 
of  the  broad  ligament  and  the  paravaginal  tissue.  It  is  commonest 
on  the  left  side,  because  parturitional  laceration  most  often  affects  that 
side  of  the  cervix.  Where  the  primary  lesion  is  in  the  body  of  the 
uterus  or  the  Fallopian  tube,  the  lymphatic  tract  accompanying  the 
ovarian  vessels  is  affected,  and  the  mass  then  lies  much  higher.  In 
posterior  cellulitis  the  parts  affected  are  the  cellular  tissue  of  the  utero- 
sacral  folds  on  either  side  of  Douglas's  pouch,  and  the  substance  of 
the  recto-vaginal  septum.  The  inflammation  in  this  case  invariably 
spreads  behind  the  rectum,  so  that  the  gut  is  encircled  by  it. 

The  histological  condition  is  one  of  lymphangitis  and  phlebitis, 
which  may  or  may  not  suppurate.  In  the  latter  case  the  abscess  may 
either  (1)  discharge  spontaneously,  above  Poupart's  ligament,  or  into 
the  bladder,  vagina,  or  rectum,  or  (2)  become  chronic  and  sequestered 
by  fibrosis. 

Symptoms. — The  onset  is  acute,  with  pain,  tenderness,  and  fever. 
After  a  few  days  an  indurated  swelling  is  felt  per  vaginam,  either  in 
front  of  or  behind  the  vagina,  or  extending  outwards  from  the  side  of 
the  uterus  to  the  lateral  pelvic  wall  as  a  buttress-like  mass. 

In  lateral  cellulitis  the  swelling  first  appears  on  the  abdomen  as  a 
tender  induration  rising  above  the  inner  third  of  Poupart's  ligament 
and  spreading  outwards  to  the  iliac  fossa.     Anterior  cellulitis  is  less 


PELVIC   CELLULITIS  ro8i 

frequently  felt  from  the  abdomen,  whilst  posterior  cellulitis  does  not 
give  rise  to  abdominal  signs.  Very  frequently  the  differenl  varieties 
coexist  (complete  cellulitis).     Femoral    thrombosis    and  "white  leg" 

often  accompany  lateral  cellulitis. 

If  pus  forms,  the  swelling  becomes  softer  and  eventually  fluctuates  ; 
large  abscesses  may  mount  under  the  peritoneum  oven  as  high  as  the 
loin,  or  sometimes  they  burrow  under  Poupart's  ligament  into  the 
thigh  and  point  at  the  saphenous  ring.  With  abscess  formation  the 
temperature  is  markedly  remittent,  and  heavy  sweating  and  rapid 
wasting  occur.  If  the  abscess  becomes  chronic,  an  indurated  fixed 
swelling  remains,  giving  rise  to  recurring  attacks  of  pain  and  fever. 
In  anterior  cellulitis  more  or  less  cystitis  is  always  present,  while  in 
posterior  cellulitis  diarrhoea  is  common. 

Diagnosis. — Acute  cellulitis  has  to  be  distinguished  from  sal- 
pingitis and  other  causes  of  acute  pelvic  peritonitis. 

The  lateral  variety  is  recognized  by  the  mass  extending  directly 
outwards  to  the  pelvic  wall,  and  mounting  upwards  towards  the  iliac 
fossa.  The  abdominal  tumour  is  dull  on  percussion,  and  there  is  a 
comparative  absence  of  intestinal  distension  and  the  other  signs  com- 
monly accompanying  peritonitis. 

Anterior  cellulitis  is  at  once  distinguished  by  its  position  between 
the  vagina  and  bladder,  while  the  swelling  of  posterior  cellulitis  does 
not  occupy  the  pouch  of  Douglas  but  lies  lower  down  in  the  recto- 
vaginal septum  and  surrounds  the  bowel  like  a  ring. 

The  mass  formed  by  a  chronic  broad-ligament  cellulitis  may  be 
mistaken  for  a  myoma  or  a  tense  cyst,  and  is  sometimes  only  distin- 
guishable by  operation.  Intraligamentous  gestation  produces  a  very 
similar  swelling,  but  has  a  distinctive  history. 

It  is  important  to  remember  that  cellulitis  and  salpingitis  often 
coexist. 

Treatment. — At  the  outset,  cellulitis  should  be  treated  by 
fomentations  applied  to  the  lower  abdomen  and  by  frequent  hot  vaginal 
douches.  In  favourable  cases  the  swelling  gradually  subsides,  and  may 
wholly  disappear  in  a  few  weeks.  If  pus  formation  is  suspected,  the 
collection  must  be  freely  incised  from  its  most  accessible  aspect, 
commonly  just  above  the  groin. 

Where  a  chronic  pelvic  mass  is  formed,  iodides  or  injections  of 
flbrolysin  may  be  tried  to  disperse  it.  These  failing,  an  operation  should 
be  undertaken.  Laparotomy  is  usually  advisable  because  in  no  other 
way  can  the  exact  nature  of  the  mass  be  ascertained.  It  may  be 
found,  for  instance,  that  the  tumour  is  really  a  tubo-ovarian  abscess 
which  has  under-burrowed  the  broad  ligament.  Encysted  broad-liga- 
ment abscesses  may  sometimes  be  enucleated  whole.  If  not,  they 
should  be  stitched  to  the  parietal  wound  and  drained. 


io82  FUNCTIONAL    DISEASES 

FUNCTIONAL   DISEASES   OF  THE   FEMALE 
GENITAL    ORGANS 

PRURITUS 

Pruritus  may  be  due  to  some  structural  change  like  leucoplakic 
vulvitis,  or  to  glycosuria,  but  cases  also  occur  in  which  no  gross  cause 
can  be  discovered,  especially  at  the  climacteric  and  during  pregnancy. 
Such  cases  are  to  be  treated  by  sedative  ointments,  and  by  the 
administration  of  bromides  internally. 

DYSPAREUNIA 

All  abnormalities  of  the  genital  tract  tend  to  dyspareunia,  but 
especially  senile  atrophy  of  the  vagina,  kraurosis  vulvae,  vaginitis, 
salpingitis,  and  fixed  retroversion  of  the  uterus.  Besides  these,  a  purely 
functional  type  exists  in  which,  with  total  absence  of  sexual  feeling, 
the  mere  idea  of  the  act  is  abhorrent.  In  cases  of  both  classes  coitus 
is  more  or  less  resisted  by  spasmodic  contraction  of  the  vaginal 
sphincters  (vaginismus).  The  two  types  are  often  combined,  for  the 
actual  pain  due  to  organic  deformity  or  disease,  by  abolishing  sexual 
feeling,  evolves  the  painful  idea  that  is  the  basis  of  the  functional 
affection  and  inhibits  the  flow  of  mucus  that  assists  the  act.  Where 
organic  deformity  or  disease  is  the  sole  or  underlying  cause  of  the 
affection  it  must  be  treated  on  the  lines  already  laid  down.  Purely 
functional  cases  are  very  difficult  to  treat.  A  plastic  operation  enlarg- 
ing the  vaginal  orifice  may  be  tried. 

DYSMENORRHEA 

There  are  four  types  of  dysmenorrhoea — (1)  "  virginal,"  (2)  obstruc- 
tive, (3)  congestive,  and  (4)  "  ovarian." 

1.  "Virginal"  dysmenorrhoea  ("spasmodic"  dysmenorrhoea). — Vir- 
ginal dysmenorrhoea  begins,  as  a  rule,  a  year  or  more  after  puberty. 
The  pain  starts  either  with  or  slightly  before  the  discharge,  and  at 
first  endures  for  a  few  hours  only,  but  in  the  course  of  years  it 
becomes  more  prolonged.  It  is  of  a  heavy,  continuous,  "  tearing  " 
character,  felt  in  the  lower  abdomen  in  the  mid-line  and  down  the 
vagina.  When  severe  it  is  accompanied  by  nausea  or  actual  sickness. 
Its  cause  is  not  known,  but  its  character  suggests  tension,  and  it  is 
probably  due  to  the  stretching  of  the  tense  peritoneum  and  rigid 
musculature  of  the  virgin  uterus  by  the  menstrual  congestion.  It 
rarely  persists  after  childbirth,  and  in  some  instances  is  improved 
by  marriage.  The  old  term  "spasmodic"  is  misleading,  for  the 
character  of  the  pain  is  continuous. 

Obstructive  dysmenorrhoea. — This  may  be  actual  or  relative.  Actual 
obstruction  is  seen  in  congenital  or  acquired  atresia  of  the  cervix  or 
vagina.    At  first  these  conditions  cause  no  pain,  because  the  cervix  and 


\n  SME  \()KKII(]    \  1083 

the  vagina  (especially)  readily  Btretch  to  accommodate  the  retained 
blood.  After  .1  while  however,  Bevere  Bpasma  of  pain  are  experienced, 
itive  obstruction  occura  when  the  menstrual  contents  are 
relatively  too  bulky  to  pass  easily  through  the  cervix.  The  best 
example  1-  of  menorrhagia  with  the  formation  of  intra-uterine 

clots,  the  expulsion  of  which  is  attended  with  strong  colicky  pain. 

A  Less  frequent  cause  is  the  Bhedding  each  month  of  a  mucosal 
from  the  body  of  the  uterus  (w  ■ 

of  which  is  associated  with  similar  distress.     In  some  of  these  cases 
the  cast-shedding  appears  to  be  a  natural  peculiarity.     In  otl 
is  the  result  of  inflammatory  change  [exfoliative  endometritis). 

Congestive  dysmenorrhoea.  ■  The  pain  of  all  uterine  and  appendage 
3e  or  displacement  is  accentuated  by  the  monthly  congestion  of 
the  parts.  This  accentuation  of  a  pain  more  or  less  constantly  presenl 
is  termed  congestive  dysmenorrhoea.  It  is  best  observed  in  chronic 
endometritis  or  salpingitis,  especially  when  associated  with  retro- 
version  or  prolapse. 

'  Ovarian  "  dysmenorrhea. — Interference  with  the  normal  dehiscence 
of  the  Graafian  follicle,  as  in  chronic  salpingo-oophoritis.  may  possibly, 
by  raising  intra-ovarian  tension,  cause  pain.  Excessive  haemoi 
into  the  follicle  after  dehiscence  may  also  produce  the  same  effect.  In 
certain  cases  of  extreme  dysmenorrhoea,  although  no  obvious  defect 
can  be  discovered  on  examination,  the  pain  is  referred  constantly  to 
the  region  of  the  ovary  on  one  or  both  sides,  and  dilatation  of  the  cervix 
has  no  effect.  Though  the  term  "  ovarian  "*  dysmenorrhoea  is  often 
used,  monthly  pain  practically  never  occurs  after  hvsterectomv  with 
conservation  of  the  ovaries. 

Treatment. — Many  drugs  are  used  for  dysmenorrhoea,  of  which 
the  most  important  are  phenaeetin,  antipyrin,  phenalgin.  antikamnia, 
guaiacum,  aletris.  styptol,  and  the  bromides.  Their  results  are 
uncertain,   and   often   only  temporary. 

Definite  organic  disease,  when  present,  must  be  treated  appro- 
priately. "'  Virginal  "  dysmenorrhoea  is  most  successfully  relieved  by 
dilating  the  uterus  up  to  12-11  Hegar  immediately  before  the  period. 

Membranous  dysmenorrhoea  is  difficult  to  cure.  Free  dilatation  of 
the  cervix  and  curettage  is  the  proper  course,  but  the  monthly  separa- 
tion of  the  cast  is  likely  to  recur. 

In  extreme  cases  of  dysmenorrhoea,  all  other  treatment  failing, 
subtotal  hysterectomy  should  be  performed.  Oophorectomy  is  never 
to  be  recommended. 

LEUCORRHCEA 

Leucorrhoni  implies  a  mucous  discharge  originating  in  the  gland 
of  the   cervix.     Though  a  functional  increase  in  this  discharge  may 


io84  FUNCTIONAL   DISEASES 

occur  during  pregnancy,  or  for  a  few  days  after  the  menstrual  flow, 
excessive  and  persistent  leucorrhoeal  discharge  is  always  due  to  cer- 
vicitis (see  p.  1010). 

METRORRHAGIA 

Bleeding  from  the  uterus  unconnected  with  the  menses  is  always 
due  to  organic  disease.  Carcinoma  of  the  uterus,  corporeal  or  cervical 
polyps,  endometritis,  and  retained  conception  products  are  the  com- 
monest causes.  The  treatment  will  be  found  set  out  under  these  con- 
ditions. 

MENORRHAGIA 

Excessive  loss  at  the  periods  is  seen  with  myoma,  adeno-myoma, 
fibrotic  metritis,  endometritis,  and  mucous  or  fibroid  polyps. 

Functional  menorrhagia  is  sometimes  seen  at  puberty,  on  the 
resumption  of  the  menses  after  lactation,  at  the  climacteric,  and  in 
certain  circumstances  unexplainable  in  our  present  state  of  knowledge. 

With  regard  to  menopausal  menorrhagia,  it  is  most  important  to 
remember  that  the  excessive  losses  are  balanced  or  more  than  balanced 
by  periods  of  amenorrhoea.  Constantly  recurring  menstrual  losses  are 
not  normal  to  this  epoch,  while  continuous  bleeding,  contrary  to  the 
public  impression,  is  altogether  abnormal,  and  should  be  immediately 
investigated. 

Treatment. — Functional  menorrhagia  is  to  be  treated  by  drugs, 
of  which  the  most  useful  are  ergot,  hydrastis,  hamamelis,  cotarnin,  and 
calcium  lactate  or  chloride.  Where  an  organic  cause  exists  operative 
treatment  is  usually  advisable. 

AMENORRHEA 

Amenorrhcea  may  be  due  to  congenital  absence  or  operative  removal 
of  the  uterus  or  ovaries.  Occasionally,  persons  structurally  normal  and 
in  good  health  never  menstruate,  probably  as  a  result  of  deficient 
ovarian  activity.  Congenital  or  postoperative  occlusion  of  some  part 
of  the  genital  canal  produces  a  spurious  amenorrhcea.  Amenorrhcea 
is  particularly  associated  with  chlorosis,  while  certain  prolonged  wasting 
diseases,  such  as  tuberculosis,  tend  to  it.  Acute  endometritis  or 
oophoritis  may  suppress  a  period,  while  the  physiological  epochs  of 
pregnancy,  lactation,  and  the  climacteric  are  normally  accompanied 
by  absence  of  the  menses. 

Treatment. — The  menstrual  flow  is  not  a  necessity  to  health ; 
its  absence,  therefore,  requires  treatment  on  the  score  of  its  cause 
alone.  In  chlorosis,  purgatives  and  iron  give  good  results.  In 
general  debility  the  usual  tonics  and  hygienic  regime  are  indicated. 
For  functional  amenorrhcea,  aloes  and  iron  are  useful. 


INDEX    TO    VOL.    II 


Abdominal    distension    in    strangulated 
hernia,  640 

examination,   methods  of,   437 

reflex  in  children,  434 

watersheds,  559 

Abnormal  anus,  451 
Abortion,  tubal,  1056 

Abscess,  anal,  subcutaneous,  684 

cold,  of  breast,  28 

in  appendicitis,  local,  547,  551 

intramammary,  17 

intraperitoneal,  572 

lingual,  176 

■ liver,  733 

mammary,  16 

perigastric,  373 

perinephric,  799 

■ periurethral.  897 

perivesical,  877 

rectal,  684 

■  retromammary,  17 

splenic,  113 

subareolar,  16 

subphrenic.  374,  572 

■ tubo-ovarian,  1048 

urinary,  897 

vulval,  989 

Acidity,  gastric,  tests  for,  309 
Actinomycosis  of  anal  canal,  698 

of  appendix,  557 

■ of  bladder,  866    • 

of  breast,  29 

of  intestines,  514 

of  salivary  grlands,  244 

of  spleen,  117 

Adeno-carcinoma  of  colon,  528 

of  kidney,  819 

of  salivary  glands,  248 

Adenoma  of  bladder,  869 

of  breast,  pure,  44 

of  colon,  multiple,  526 

of  ovary,  1078 

of  rectum,  711 

of  salivary  glands,  248 

of  small  intestine,  525 

of  stomach,  377 

of  testis,  942 

Adenomatosis  vagina?.  996 
Adeno-myoma   of   Fallopian   tube,   1064 

of  uterus.  1045 

Adeno-sarcoma.    embryonic,   of   kidney, 

820 
Alimentary  canal,  development  of.  439 
Allantois,  665 
Amastia,  7 
Amenorrhoea,  1084 
Anaemia,  splenic.  111 
Anal   abscess,   subcutaneous,  684 

canal,  actinomycosis  of,  698 

anatomy  of.  659 

■ blood  supply  of.  663 

carcinoma  of,  726 


Anal  cjii.i1.  diphtheria  of,  694 

examination  of,  664 

fibroma  of,  714 

flstulae  of.  687 

inflammation  of  (see  Proctitis) 

malformations  of,  665 

muscles  of,  661 

papilloma  of,  714 

stricture  of,  704 

syphilis  of.  697 

tuberculosis  of,  697 

ulceration  of,  698 

treatment  of,  701 

Assure,  682 

sinus,  691 

veins,  dilatation  of,  673 

Aneurysm  of  renal  artery,  798 
Angioma  of  liver,  737 

of  small  intestine,  525 

of  spleen,  cavernous,  118 

Ankyloglossia,  168 
Ano-coccygeal  body,  659 
Anorchism,  924 

"  Anorectal  syphiloma,"  698 
Antiperistalsis  of  colon,  428 

of  small  intestine,  427 

Anuria,  781 

calculous,  837 

— —  diagnosis  of,  838 

pathology  of.  837 

prognosis  in.  839 

symptoms  of.  838 

treatment  of,  839 

circulatory,  782,  783 

from  loss  of  renal  tissue,  782 

hysterical.  782.  783 

in  renal  calculus,  844 

infective,  782.  783 

reflex,  782,  783 

urinary-pressure,  782 

Anus,  abnormal,  451 

artificial.  451 

pruritus  of,  727 

Aphthous  vulvitis.  987 

Appendicectomy   in    acute    appendicitis, 

550.  552 

in  chronic  appendicitis,  554 

Appendices  epiploicse,  423 

strangulation  of  intestines  by, 

482 
Appendicitis.  540 

accessory  causes  of,  540 

acute,  545 

forms  of,  544 

clinical  features  of,  544 

diagnosis  of.  548 

treatment  of,  549 

. by     appendicectomy, 

550,  552 
symptoms  of.  545 
treatment  of.  550 
with  diffuse  peritonitis,  547 


10S5 


lo86 


INDEX  TO  VOL.  II 


Appendicitis,    acute,    with    diffuse   peri- 
tonitis,  treatment  of,   550 

with  local  abscess,  547 

treatment  of,  551 

bacteriology  of,  540 

chronic,  552 

appendicectomy  in,  554 

diagnosis  of,  553 

morbid  anatomy  of,  541 

relapsing    (see    Appendicitis,    chro- 

nic) 
Appendicular  colic,  553 
hernia,     operative     treatment     of, 

631 
Appendix,  actinomycosis  of,  557 

anatomy  of,  537 

and  intestinal  obstruction,  557 

average  dimensions  of,  537 

blood-vessels  of,  538 

in  hernias,  476,  557,  584,  588 

in  intussusception,  557 

■ ■  lymphatics  of,  538 

peritoneal  relations  of,  538 

physiology  of,  538 

misplacements  of,  539 

rare  diseases  of,  555 

strangulation  of  intestine  by,  482 

structure  of,  538 

tuberculosis  of,  557 

tumours  of,  556 

variations  in  position  of,  537 

Areola  of  breast,  diseases  of,  8 
Ascites,  579 

Atmocausis     in     chronic     endometritis, 

1015 
Atony  of  bladder,  851,  881,  882 
Atresia,  congenital,  of  cervix  uteri,  998 

of  oesophagus,  259 

of  pylorus,  311 

Atrophy  of  testis,  940 
Auscultation  of  abdomen,  439 

of  oesophagus,  256 

Axillary     glands,     enlargement    of.     in 

breast  carcinoma,  73 
•  in  chronic  mastitis,  24 

tail  of  breast,  2 

Azoospermia,  941 


Bacilluria    (see   Bacteriuria) 

Bacillus  coli  group,  436 

lactis  aerogenes  in  intestines,  437 

putriflcus  in  intestines,  437 

pyocyaneus  in  intestines,  437 

tuberculosis  in  intestines,  437 

Bacteria,  intestinal,  436 
Bacteriuria,  783 

pathology  of,  783 

prognosis  in,  784 

symptoms  of,  784 

■ treatment  of.  784 

"  Ballooning  of  rectum,"  472 
Banti's  disease,  hypertrophy  in,  112 
Bardeleben's  (von)  modification  of  Blan. 

din's  operation,  142 
Barker's  operation  for  inguinal  hernia, 

619 
Bartholin's  gland,  cysts  of,  990 
Bartlett's     filigree     implantation,     Mc- 

Gavin's    modification   of.    629 
Bassini's  operation  for  inguinal  hernia, 

619 
Battle's  incision  in  appendicectomy,  554 
Bier's  treatment  in  acute  mastitis,  18 

in    septic    epididymo -orchitis. 

932 

in       tuberculous       epididymo- 

orchitis,  938 

mastitis.  29 

Bifid  tongue,  168 


Bile-duct,    common     (see   Common  bile- 
duct) 
Bile-ducts,  730 

carcinoma  of,  762 

■ •  gall-stones  in,  746 

inflammation  of,  743 

■  injuries  to,  741 

■ ■  obliteration  of,  congenital,  740 

stricture  of,  751 

syphilis  of.  742 

tuberculosis  of,  741 

tumours   of,   innocent,  760 

■  malignant,  760 

Bilharziosis  of  kidney  and  ureter,  832 

Biliary  calculi    (see   Gall-stone   disease) 

Bipartite  palate,  145 

Black  tongue,  184 

Bladder,  actinomycosis  of,  866 

adenoma  of,  869 

anatomy  of,  845 

atony  of,  851,  881,  882 

carcinoma  of,  869 

course  and  prognosis  of,  870 

diagnosis  of,  870 

■ symptoms  of,  870 

treatment  of,  operative,  870 

palliative,  871 

cholesteatoma  of,  869 

diverticula  of,  855 

effect  of  nerve  injuries  on,  881 

examination  of,  846 

exploration  of,  847 

extroversion  of.  854 

female,  anatomy  of,  846 

foreign  bodies  in,  877 

hernia  of,  584,  614,  856 

inflammation  of   (see  Cystitis) 

influence    of    nervous    diseases    on, 

880 

inversion  and  prolapse  of,  856 

lymphatics  of,  846 

■ papilloma   of,  malignant,   869 

villous,  866 

■ rupture  of.  857 

sarcoma  of,  872 

stone  in  (see  Vesical  calculus) 

suprapubic  fistula  of,  878 

syphilis  of,  866 

■  wounds  of.  859 

Blandin's    operation,    von    Bardeleben's 

modification  of,  143 
"  Blind  hernia,"  601 
"  Brawny  arm,"  67 

treatment  of,   96 

Breast,  abscesses  of,  16,  28 
absence  of,  congenital,  7 

actinomycosis  of,  29 

■  adenoma  of,  pure,  44 

anatomy  of,  1 

axillary  tail  of,  2 

blood  supply  of,  3 

cancer  "  en  cuirasse  "  of.  66 

cancerous  ulcers  of,  treatment  of,  98 

■  carcinoma  of,  50 

acute,  80 

after-treatment   in,   93 

age-incidence  of,  50 

atrophic  scirrhous,  79 

"  brawny  arm  "  in.  67 

cause  of  death  in,  93 

chronic  mastitis  as   precursor 

of.  50 

clinical  classification  of,  52 

columnar-celled,  84 

contrast    of    permeation    and 

infiltration    in,    64 

degeneration  in,  70 

— diagnosis  of,  75 

diffuse,  53 

dimpling  of  skin  in,  71 


INDEX   TO   VOL.   II 


[087 


Breast,  oarcinoma  of,  dissemination  of. 

54 

parietal.  55 

visceral,  62 

duct  papilloma  and,  52 

enlargement        of        axillary 

glands  in,  73 

— —  etiology  of,  50 

exploratory  incision    in,  86 

fibro-adenoma  and,  51 

histological  varieties  of,  52 

impalpable,  82 

- — -  incised,  microscopical  examina- 

tion of,  87 
naked-eye    characters    of, 

86 

inoperable,  treatment  of,  94 

lymphatic  obstruction  in.  65 

medullary,  78 

mobile,  83 

natural  repair  in,  69 

operation   for,    Eandley's,  88 

principles  of,  87 

■ technique  of,  88 

pachydermia  in,  66 

—  pathological    classification    of, 

70 

"  peau  d'orange  "  in,  65 

peripheral,  80 

"  pig-skin  "  in,  65 

plastic  operations  in,   93 

prognosis  in,  77  • 

retraction     and     elevation     of 

nipple  in,  74 

serous  effusions  in,  69 

signs  of,  71 

sites  of,  50 

soft,  78 

symptoms  of,  71 

treatment  of.  87,  94 

varieties  of,  unusual,  78 

chondro-sarcoma  of,  101 

cold  abscess  of,  28 

cystic  disease  of,  20 

cysts  of,  31 

diagnosis  of,  34 

■  hydatid,  33 

development  of,  5 

developmental  abnormalities  of,  7 

duct  carcinoma  of,  84 

papilloma  of,  46 

clinical  features  of,  47 

cystic,  49 

etiology  of.  46 

fungating,  49 

morbid  anatomy  of,  46 

■  ■  treatment  of,  49 

elephantiasis  of,  30 

fibro-adenoma  of.  36 

and  carcinoma.  51 

and  chronic  mastitis,  23 

■  and  sarcoma.  99 

cystic,  43 

differential  diagnosis  of,  39 

etiology  of,  36 

■ ■  fungating  cystic,  44 

morbid  anatomy  of,  37 

origin  and  development  of,  37 

soft,  40 

symptoms  and  signs  of,  39 

treatment  of.  39 

eumma  of,  29 

— — ■  hematoma  of.  30 

■  hyperplasia  of.  8 

■  involution  of.  6 

limits  of.   2 

■  lipoma  of,  49 

lymphatic    arrangements    of    skin 

of,   5 
■ vessels  of,  3 


.  male,  paroinoma  of,  85 
hypertrophic  enlargement  of,  8 

in  11   <  ].  -   of,  2 

in\  10m a  of,  49 

sarcoma   of,   98 

age-incidence  In,  99 

clinical   siu'ns  of,  100 

diagnosis  of  breast  carcinoma 

from,  77 
etiology  of,  98 

fibro-adenoma    and,   99 

treatment  of,    102 

supernumerary,  7 

tuberculosis  of,  26 

tumour-  of,  35 

(sec  also  Nipple) 

Bright's  disease,  813 
Broad-ligamenl  cyst  b,  1069 

myomas.  1032 

Broncho-pneumonia,    septic,    after   kelo- 

tomy,  '55 
Brophy's  operation  for  deft  palate,  151 
Bruning's  electroscope,  258 
Bubonocele,  595 
Burns  and  scalds  of  tongue,  171 

Cfecum.  actinomycosis  of.  514 

blood    supply   of,   424 

carcinoma  of,  530,  533 

hernia  of,  613 

surgical  anatomy  of,  423 

Calcareous   degeneration    in    carcinoma 

of  breast,  70 

in  myoma  of  uterus,  1033 

Calculi,  biliary  (see  Gall-stone  disease) 

intestinal,  501 

pancreatic,  775 

prostatic,  908 

■ salivary,  243 

under  prepuce,  973 

Calculus,  renal  (see  Renal  calculus) 

ureteral  (see  Ureteral  calculus) 

■  urethral,  888 

vesical  (see  Vesical  calculus) 

Calmette's  test  in  renal  tubercle,  829 
(anal  of  Nuck,  hydrocele  of,  990 
Cancer  "en  cuirasse,"  66 

(see  also  Carcinoma) 

Cancerous  pachydermia,  66 
Carcinoma  of  anal   canaL  726 

of  bile-ducts,  762 

of  bladder  (see  Bladder,  carcinoma 

of) 

of  breast  (sec  Breast,  carcinoma  of) 

of  caecum,  530,  533 

of    cervix    uteri    (see   Cervix    uteri, 

carcinoma    of) 

of  colon  (see  Colon,  carcinoma  of) 

of  corpus  uteri,  1027 

of  duodenum  (see  Duodenum,  carci- 

noma of) 
of  Fallopian  tube.  1063 

of  gall-bladder.  760 

■  of  kidney,  819 

of  liver.  738 

of  myomatous  uterus,  1035 

■  of  nipple.  10 

of     oesophagus      (see     GEsophagus, 

carcinoma  of) 

of  ovary. 1079 

■  of  pancreas,  774 

of  penis,  975 

of  prostate,  919 

of  rectum   (sec  Rectum,  carcinoma 

of) 

of  salivary  glands,  248 

of  scrotum.  980 

of  small  intestine,  525 

of    stomach    (see    Stomach,    carci- 

noma of) 


io88 


INDEX   TO   VOL.   II 


Carcinoma  of  testis,  944 
of  tongue  !.-'<■<'  Tongue) 

of  vagina,  997 

of  vulva,  991 

Cardiospasm,  'li~ 
Caruncle,   urethral,   989 

"  Caseous  "   degeneration   in   myoma   of 

uterus,    1034 
Castration  (see  Orchidectomy; 
Cataphoresis,  zinc,  in  rectal  ulceration, 
702 

in  salivary  carcinoma.  248 

Catheter  fever,  884 

Catheterization  in  chronic  enlargement 

of  prostate,  915 
■ in  examination  of  bladder,  846 

of  ureters,  780 

"  Cauliflower  excreacence,"  1021 

tics,  injury  to  stomach  by,  339 
Cautery  in  glossodynia  exfoliativa.  180 
■  in  rectal  prolapse,  710 

in  recto-vaginal  fistula,  693 

in  recto-vesical  fistula,  692 

in  venereal  warts,  987 

Cellulitis,  pelvic,  1052,  1080 

scrotal,  979 

Cervicitis,  1008 
Cervico-vagino-vulvitis,  986 
Cervix  uteri,  atresia  of,  998 

carcinoma  of,  1018 

clinical  types  of,   1021 

diagnosis  of,   1022 

etiology  of,  1018 

inoperable,    1027 

pathology  of,  1019 

symptoms   of,    1020 

treatment   of.   1022 

cysts   of,   1017 

elongation  of,  999 

inflammation  of,   1008 

polypus  of,  1017 

Chancre  of  nipple,  13 

of  tongue,   hard,   191 

■  soft,    192 

of  vulva,   986 

perianal,    soft,    698 

Cheatle's   modification   of  Kocher's  ope- 
ration for  lingual  carcinoma,  223 
Chimney-sweep's  cancer,"  980 
Cholangitis,    743 
Cholecystectomy,   753 
Cholecy-tendesis,   757 
Cholecvstenterostorny    in    carcinoma    of 

bile-ducts,  762 
of  pancreas,  775 

in   chrome    pancreatitis,   770 

Cholecystitis,   742 

Cholecystostomy    in    gall-stone    disease, 

757 
Cholesteatoma  of   bladder,    869 
Chondro-sarcoma  of   breast,   101 
Chorion-epithelioma  of  uterus,   1028 
Cicatricial  stricture  of  intestine,   522 
Circumcision,   971 
Cirrhosis   of   liver,   736 

of  stomach,    398 

Cleft    palate   (see   Palate,   cleft; 
Cloaca,   665 

persistence  of  original  communica- 
tion with.  667 
Cock's  operation.  896 
Coley's  fluid  in  parotid  sarcoma,  249 
Colitis,    chronic,    508 

haemorrhagic,    509 

ulcerative.  520 

Colloid    degeneration    in    breast    carci- 
noma, 70 
.  action  of.  in  defaecation,  429 

adenoma  of,  multiple,  526 

antineristalsis  of,  428 

bacillus  peritonitis,  565 


Colon,  blood  Bupply  of,  424 

carcinoma  of,  527 

clinical  features  of,  531 

complications  of,    533 

■ ■ ■  differential  diagnosis  of.    535 

morbid  anatomy  of,   528 

sites   of,   531 

treatment   of,    535 

complete  excision  of,  304 

constriction   rings  in,   428 

diverticula   of,   t4l 

■ — -  enteroliths    in,    502 

fibromatosis  of,   515 

idiopathic   dilatation   of,   446 

■  innervation  of,   430 

■  movements   of,    428 

■  nutrient  enemata   and,  430 

occlusions   of,   congenital,   440 

oscillating  contractions  in,  429 

pelvic,    actinomycosis    of,    514 

carcinoma  of,  531,   533 

faecal  accumulations  in,   502 

volvulus   of,  494 

rupture  of,   457 

sarcoma  of,  536 

splenic    flexure    of,    carcinoma    of. 

533 

surgical  anatomy  of.  423 

transverse,  carcinoma   of,   533 

Colostomy  in  rectal  and  anal  stricture, 

706 

ulceration,   703 

Colpocleisis,   993 

Colporrhaphy,    anterior,     in    cystocele. 
994 

in  prolapse  of  uterus,  1003 

posterior,   in   rectocele,   995 

Common   bile-duct,   730 

cystic   dilatation   of,   740 

hepatic   duct,   730 

Concretions    in    vesiculae    seminales,   924 

Congenital  abnormalities  (see  under 
tne  various   organs; 

Constipation  habitual,  surgical  treat- 
ment  of,    504 

Constriction   of   penis,    974 

rings  in   colon,   429 

Contusion   of   penis,  973 

Cord,  spermatic  dee  Spermatic  cord) 

Cracked  nipple,   9 

<  ryoscopy,    779 

Curettage  in  chronic  endometritis,  1014 

Cutaneous   hyperalgesia,   433 

in  disease  of  stomach,  304 

■ piles,   674 

Cvstadenoma    of    breast,    fungating,    44 

of  liver,   738 

of  ovary,   1067 

of  pancreas,   771 

papillary,   of   breast,   46 

Cystectomy  in  vesical  carcinoma,  871 

in    villous    papilloma    of    bladder, 

869 
Cystic   artery,   730 

degeneration  in  myoma  of  uterus, 

1034 

disease   of   breast.   20 

of   liver,    multiple,   738 

duct.   729 

fibro-adenoma   of   breast,   43 

Cysticotomv  in  gall-stone  disease,  757 
Cystitis,  860 

acute,    treatment    of,    862 

bacteriology   of,    860 

■  chronic,   treatment  of,  862 

complications  of,   861 

cystoscopy   in,    860 

diagnosis   of,   86x 

due   to  nervous   disease,   881 

pathological  anatomy   of,   860 

prognosis   in,   862 


INDEX   TO   VOL.   II 


1089 


GystitiB,  Bubacute,  treatment   of,  862 

symptoms  of,  861 

treat  meal    ol 

taberou ions,  863 

oele.   994 

urethral,  856 

.    direct .   847 
• in   enlarged    prostate,  915 

in  1  treign  b  »dies  in  bladder,  877 
in  hsemal  uria,  786 

in  prolapse  of   ureter,  840 

in  rena  1  calculus,  835 

in  solitary    kidney,  789 

in  ureteral  calculus,  844 

in  vesical   oalculus,   875 

in  villous   papilloma   of  hladdcr.  668 

indirect,  847 

ostomy   in    rectovesical   fistula,  692 
Cystotomy     in     villous     papilloma     of 

bladder.    868 

suprapubic,    in    urethral    stricture, 

896 
Cysts,  hydatid.  oJ    breast,  33 

of  kidney.    825 

of  liver,    Vo6 

of  peritoneum,   578 

■ of  spleen,    118 

perivesical,    857 

in  hernial  sacs.  586 

mesenteric,  of   peritoneum,  579 

of    Bartholin's   gland,   990 

of  breast,  31 

diagnosis  of,  34 

of  cervix    uteri.    1017 

■ ■  of  epididymis.    945 

of  kidney,  824 

of    labium,   990 

- — ■  of  liver,   738 

■  of  ovary    (see   Ovarian   cysts) 

of  pancreas,   770 

of  salivary    ducts,   245 

glands,   246 

of  stomach,   37/ 

of  testis,   947 

of  tongue,    195 

of  tunica    aibuginea,    947 

of  urethra,  901,   990 

of  vagina,    996 

of  vesiculoe    seminales,    924 

of  vulva,   990 

proliferous,  of  breast,   46 

sebaceous,  of  scrotum,  981 

simple  subareolar,  33 

Deep  tenderness  in  gastric  diseases,  304 
Defsecation,   action  of   colon   in,   429 
Dental   ulcers,    186 
Dermoids   of   ovary,    1068 

of  testis,    945 

of  tongue,    195 

"  Desmoid  "    test   of  Sahli,   310 

Diaphragmatic   hernia.   476 

Diaphrenic  invasion  in  breast  carci- 
noma,  63 

Dietl's   crises.   793 

Dilatation  of  stomach  (see  Stomach, 
dilatation   of) 

Dimpling  of  skin  in  breast  carcinoma, 
72 

Diphtheria,    rectal  and   anal,  694 

Dislocation   of  penis,   973 

Dissemination  of  breast   carcinoma,  54 

Diverticula,  distension,  581 

duodenal.    313 

gastric.    313 

intestinal,    440 

oesophageal  !  sophagus,  diver- 

ticula of) 

traction,    581 

vesical,   855 

Diverticulitis.    141, 

7,  r 


443,   510 


:  loulum,     Mecki  i  -  (feci  • 

divert  Loulum  | 
Doable-filigree   in   large   icrotal  henna. 

Duckbill    speculum    in    examination    ol 

i  BOl  uiii    a  ml    a  mi  I    CS  ua  I.    664 

Duel   carcinoma  ol    breast,  84 

papilloma    ol     breast,    49 

ami  carcinoma,  52 

chronic  mastitis  In,  23 

Duodena]  diverticula,  313 

fistulas,  403 

hernia,  475 
ulcer,    359 

age-incidence  of.  360 

complies  t  ion-   of,  364 

diagnosis  of,  364 

el  iology   of,  359 

gastroenterostomy  in,  365 

hasmatemesis   from,  371 

perforation    of,    366 

— -     prognosis   in,   365 

Bex-incidence  of,  361 

situation    of.   362 

—      symptoms    of,   362 

test    meal   iu,  364 

— ■  treatment   of,   365 

Duodenum,  anatomy  of,  299 

bacteriology   of,  302 

blood    supply    of,    3U0 

carcinoma    of,    392 

prognosis   in,   393 

symptoms    of,   392 

—     treatment   of,  393 

clinical    examination    of,    302 

disease  of,  appetite  in,  305 

haemorrhage    in,    305 

■ jaundice    in,    305 

pain    and    tenderness    in,    303 

vomiting   in,    305 

diverticulum   of.  313 

■  fibro-myomas   of,   376 

foreign  bodies   in,  ?37 
■  injuries   of,    331 

malformations    of,    311 

misplacements    of,    311 

myoma  of,  376 

occlusion    of,    312 

physiology    of,    299 

rupture   of,    334 

sarcoma   of,   396 

■  stricture    of,    312 

tumours    of,    benign,    375 

malignant,    392 

ulcer  of   (see   Duodenal  ulcer) 
Dysenteric   stricture,   519 

ulceration,    519 

Dysentery    involving    rectum,    698 
Dysmenorrhea,  congestive,  1083 
■  obstructive,  1083 

"  ovarian,"    1083 

"  spasmodic,"  1082 

"virginal,"  1082 

Dyspareunia,  1082 
Dyspeptic   tongue.   178 

ulcers    of    tongue,    185 

Dysphagia    in    oesophageal    carcinoma. 

287 
■ obstruction,    274 

Ectopic  spleen,  1C9 

testis.  925 

Eczema  of  nipple,  9 

icity  in  vesical  atony,  882 
Electrolysis  in  oesophageal  stricture,  282 
Elephantiasis  of  breast,  30 

-  of  scrotum,  981 

Embolic    theory    of    dissemination    of 

breast  carcinoma,  54 
Embolism  of  mesenteric  blood-vessels,  506 
Bmhryomaa  of  ovary.  1068 


1090 


INDEX   TO   VOL.  II 


Endocervicitis,  1008 

• acute,  1008 

•  chronic,  1008 

clinical  features  of.  1010 

differential  diagnosis  of,  1010 

■ ■ treatment  of,  1010 

Endometritis,  acute,  1012 

chronic,  1012 

•  exfoliative,  1083 

polypoid,  1013 

senile.  1014 

—  tuberculous,  1015 
Endometrium,  hypertrophy  of,  1016 
Endothelioma  of  testis,  944 
- — -  of  tongue,  204 
Enterocele,  partial,  612 
Enteroliths,  501 
Enteroptosis,  450 
Enterospasm,  507 
Enuresis,  essential,  849 

nocturnal,  849 

Eosinophilia  after  splenectomy,  103 
Epidemic  parotitis,  240 
Epididymectomy     in     tuberculous     epi- 

didymo-orchitis,  938 
Epididymis,  cysts  of,  945 

malignant  disease  of,   945 

Epididymitis  complicating  hernia,  637 
Epididymo-orchitis,  930 

and  strain,  934 

■ septic,  931 

syphilitic,  939 

tuberculous,  935 

■  in  children,  938 

Epigastric  invasion  in  breast  carci- 
noma, 63 

Epispadias,    967 

Epoophoronic  cysts,   1070 

"  Erosion,"  cervical,  1008 

Erysipelatous  vaginitis,   995 

Erythema    migrans,    177 

Ewald's  salol  test  of  gastric  motor 
power,    309 

Extra-uterine  pregnancy  (see  Ovarian 
gestation,    Tubal    gestation) 

Extravasation  of   urine,    898 

Extroversion    of    bladder.    854 

Face,   development   of,    121 

malformations   of,    121,    126 

Facial   cleft,    127 

Facies     Hippocratica     in     strangulated 

hernia,  641 
Faecal    accumulations,    502 

concretions,    501 

fistula,    453 

Faeces,     changes    in, 
creatitis,    768 

constituents   of, 

examination    of,    311 

Fallopian    tube,    adeno-myoma   of,    1064 
carcinoma  of,  1063 

gestation  in   (see  Tubal  gesta- 

tion) 

■ in  hernial  sacs,   584 

inflammation      of      (see      Sal- 
pingitis) 

strangulation  of  intestines  by, 

482 
Female    genital    tract,    984 

examination    of.    984 

Femoral  hernia  (see  Hernia,  femoral) 

Fever,    urethral,    884 

Fibro-adenoma    of    breast    (see    Breast, 

fibro-adenoma   of) 
Fibroid    breast,    20 
Fibroids  of  uterus   (see  TJterus,  myoma 

of) 
Fibroma   of  ovary,    1078 

of  rectum   and   anal   canal,  714 

— —  of  small  intestine,   525 


in    chronic    pan- 

435 


Fibroma  of  stomach,   375 
■ of   testis,    941 

of    vagina,    997 

■  subperitoneal,    simulating    hernia, 

608 
Fibromatosis   of    colon,    515 

of  stomach,    398 

Fibro-myoma    of    stomach    and    duode- 
num, 375 

of   uterus,   1033 

Fibrotic     degeneration     of    myoma     of 
uterus,   1033 

metritis,    1016 

Filigree,  double-,  in  large  scrotal  hernia, 
622 

implantation,    suppuration    follow- 

ing,   636 

in  appendicular  hernia,  632 

in    lumbar    hernia,    632 

■ in    umbilical    hernia,    628 

method   of   constructing,    623 

implanting,    624 

■ spider-web,    oot 

in    femoral    hernia,    627 

• in   perineal  hernia,   634 

Fissure,   anal,    682 

Fistula,  anal,  intermuscular,  688 

superficial,    687 

supramuscular,  690 

due    to    gall-stone    disease,    748 

duodenal,    403 

faecal,   453 

complicating   hernia,    636 

treatment       of       strangulated 

hernia  by,  651 

gastric,    4ou 

gastro-colic,    402 

internal,   and  carcinoma  of   colon, 

534 

intestinal,    external,    453 

internal,    455 

treatment       of       strangulated 

hernia    by,    651 
■ of   lip,    128 

pancreatic,  775 

perirenal,  812 

rectal,    bone   disease   and,    693 

■ tuberculous,    695 

recto-urethral,   693 

■ recto-vaginal,    693 

recto-vesical,    692 

- — ■  renal,    812 

salivary,    236 

■  "  stomach-gall-bladder,"    403 

ureteral,  842 

■  urethral,  899 

urinary,    complicating   hernia,    636 

vaginal,   993 

vesical,  suprapubic,  878 

vesicointestinal,    879 

vesico-vaginal,   880 

Fixation-of -complement  test  in  peri- 
vesical hydatid  cysts,  857 

in  renal  hydatid  disease,  826 

in  syphilitic  epididymo-orchi- 
tis, 940 

Floating   kidney,   791 

lobe   of   liver,    731 

Floor    of    mouth,    234 
Follicular    cysts   of   ovary,    1067 
Foramen  of  Winslovv,  hernia  into,  476 
Foreign    bodies    in    bladder,    877 
in  intestines,  462 

in  oesophagus  (see  (Esophagus, 

foreign    bodies    in) 

in    stomach    and    duodenum, 

337 

in    urethra,   889 

Fossa,   ischio-rectal,    663 

Fracture  of   penis,   973 

Fraenum  of  prepuce,   rupture  of,  973 


I\l)l  \   TO   \  OL.   II 


1091 


Frssnum  of  prepuce,  shortnesi  of,  973 

mgue,    ul'  11    of,    187 
Fungating  Bbro-adenoma      "f 

breast.  44 
Puniculitis,    endemic,    964 
Furrow  <il    tongue,    179 

Galactocele,   32 

Gall-bladder,    anatomy    of,   729 

carcinoma    of,    /t>0 

inflammation    of,    742 

injuries    of.    741 

tuberculosis   of.    741 

tumours  of.  760 

Qall-etone    disease.    743 

after-treatment    of,     759 

cholecystectomy    in,   758 

cholecystostomy    in.    757 

— ■  cysticotomy   in.   757 

diagnosis   of.    .  54 

etiology   of.    7-3 

fistula   due   to.   748 

inflammation    due    to,    744 

intestinal    obstruction    du. 

752 

pathology    of,    743 

prognosis    in,    754 

signs  of.  753 

stricture  of   bile-ducts  due  to. 

751 

symptoms  of,   752 

treatment    of,    operative,   755 

results  of,  759 

palliative,   754 

■ with  jaundice.  753 

wit-hout  jaundice,  753 

ileus,  499 

■  obstruction,   499 

— — chronic,  501 

Gall-stones   in   bile-ducts,   746 

Gangrene  of  tongue,   177 

Gangrenous   vaginitis.   995 

Gastrectomy,   complete,   406 

—  in   carcinoma   of  stomach,  390 

partial,  404 

in  carcinoma  .  of   stomach.   390 

in   hour-glass   stomach,    324 

Gastric   adhesions.  358 

diverticula,   313 

■ fistula?,    400 

external,  401 

internal,   402 

operations,  404 

ulcer,   340 

acute,  343 

after-treatment   of,   353 

•  age-    and   sex-incidence   of.   340 

and  carcinoma  of  stomach,  379 

chronic.   345 

ha?matemesis   from,   371 

■  complications  of,  347 

diagnosis  of,   347 

etiology  of.  340 

immediate.   341 

gastrojejunostomy  in,  351 

haemorrhage  and.   346 

morbid   anatomy   of.  344 

pain  and.  345 

perforation  of.  353 

■ ■  after-treatment    of,    358 

diagnosis   of.   355 

prognosis  in.   356 

■ —  ultimate,   358 

symptoms  of.  354 

treatment    of.    356 

vomiting    and.    355 

prognosis  in.   350 

saddle-shaped,    and   hour-glass 

stomach.  321 

site   of.    344 

symptoms  of,   344 


ulcer,  treatment  of,  350 
tuberculous,  397 

\'  I.  346 

•  iviilus.    321 
-.   phlegmonous,  399 
submu  on*,   399 

ills,  402 
duodenostomy,  418 

in   gastroptosiB,   320 

i ..t-t ro-enl erostomy,   406 

anterior    \  I  .    417 

in    duodenal    ulcer,   365 

in   Y.    410 

peptic   ulcers  Following,  517 
Gastro-jejunal  nicer,  517 
o-jejunostomy,  406 

anterior.   408 

no-loop,  408 

closure  <>f  opening  after,  417 

complications   of,    413 

diarrhoea  after,  417 

hasmorrhage   after.   413 

in   carcinoma    of   stomach.   388.    391 

■ in  gastric    ulcer.   352 

perforated,  357 

in  gastroptosis.  320 

in   hour-glass  stomach,   324 

intestinal  obstruction   after,   417 

■  peptic   jejunal  ulcer   after,   415 

posterior,  406 

regurgitant  vomiting  after,  413 

results    of,    411 

Gastroptosis,   319 

Gastroscope  of  Hill-Herschcll.   308 

of   I.eiter,   307 

of    Sout tar-Thompson.   308 

Gastrostaxis,  340 

Gastrostomy    in    carcinoma    of    oesopha- 
gus. 292 
of    stomach.   391 

in    foreign    bodies    in    oesophagus. 

273 

■  in   stricture  of  oesophagus,   282 

Genital   tract,    female,   984 

examination  of,  984 

■  male,   907 

"  Geographical  tongue,"   177 
Gerlach's   valve.    537 
Gestation,    ovarian,    1065 

■ sac,   1055 

rupture  of  primary,   1055 

■ secondary,   1065 

tubal   (see  Tubal  gestation) 

Glenard's   disease,   450.   581,   613 
Globus  hystericus,  274 
Glossitis,   acute  superficial,  173 
deep.    174 

indurative,  175 

membranous.   173 

mercurial,    175 

nervous,   173 

parenchymatous,   174 

pellicular,    173 

• ■  syphilitic,    193 

Glossodynia   exfoliativa.   180 
('.luteal  hernia    (see   Hernia,   gluteal' 
Gmelin's   test    for   bile   in   vomit.   310 
Gonococcal   peritonitis,   acute,   567 
chronic.    575 

vaginitis.   996 

■  vulvitis.  986 

Gonorrhoea]  proctitis.   694 

vesiculitis,   923 

Granulomata.     infective,     of     salivary 

glands,   244 
Grunxburg's    test.    309 
Gumma   of  breast.   29 

of  kidney,    831 

of  spleen,    118 

of  testis.  939 

- — -  of  tongue.    194 


logz 


INDEX  TO  VOL.   II 


Gunshot  wounds  of  intestines,   460 

of   stomach,    336 

Gynecomastia,   8 

Heniatemesis,  369 

from  duodenal  ulcer,   371 

. from  gastric  ulcer,   371 

. postoperative,  370 

Hematocele  of  spermatic  cord,  961 

diffuse.  962 

encysted,   962 

of  tunica  vaginalis,  958 

. . diagnosis  of,   960 

etiology  of,    958 

. pathological   anatomy   of, 

959 

■ symptoms  of,  959 

treatment  of,  961 

■ ■  peritubal,    1056 

■ tubal,    1056 

Hematocolpos,  992 
Hematoma  of  breast,   30 

of    scrotum,    complicating    hernia, 

634 
Hematosalpinx,   1056 
Hematotrachelos,   992 
Hematuria,  785 

diagnosis  of  cause  of,  786 

essential  renal,   786 

■ ■  in   renal   calculus,    835,    836 

in  ureteral  calculus,   844 

in   vesical   carcinoma,    871 

in    villous    papilloma    of    bladder, 

868 
■ localization  of  source  of,  785 

renal,  treatment  of,   787 

■  treatment  of,  787 

unilateral,   treatment  of,  787 

■ vesical,   treatment  of,   787 

Hemorrhoidal   arteries,   663 
Haemorrhoids    (see    Piles) 
Hagedorn's  operation  for  double  hare- 
lip,   14i 

Halsted's  method  of  closing  inguinal 
canal,    619 

Handley's  operation  for  breast  carci- 
noma, 88 

Hare-lip,   128 

after-treatment  in,  137 

bilateral,   131 

operation   for,  Hagedorn's,  143 

Rose's,   143 

lateral,   130 

median,   129 

■ operation   for,    134 

choice  of,  144 

treatment  of,  132 

unilateral,  131 

operation  for,   Mirault's,   139 

Nelaton's,   138 

Owen's,  140 

Rose's,  138 

Hairy  tongue,   184 
Hemiglossitis,    175 
Hepatoptosis,  731 
Hermaphrodism,  pseudo-,  968 
Hernia,   580 

after-treatment   of,   638 

■ anatomical  varieties  of,   592 

■ appendicular,   operative    treatment 

of.   631 
by   filigree,   632 

"blind,"   601 

causes   of  irreducibility   of,  591 

clinical    characters   of,    590 

complete  median,   604 

congenital,   581 

—i of  canal  of  Nuck,  582 

of   funicular   process.   582 

of   vaginal   process,   582 

defecation   and,   589 


Hernia,  diaphragmatic,  476 

duodenal,    4/5 

etiology   of,   589 

femoral,   596 

diagnosis   of,    598 

strangulated,  643 

treatment   of,   649 

treatment  of,  626 

by   "  spider-web  "   filigree, 

627 

gluteal,    607 

operative  treatment  of,  633 

strangulated,  treatment  of,  650 

incarcerated,    591 

inguinal,   diagnosis   of,    595 

direct.  5y4 

oblique,    592 

operation   for,    619 

Barker's,    619 

Bassini's,   619 

Kocher's,   619 

Macewen's,  619 

strangulated,   642 

treatment  of,   649 

symptoms   of,    595 

intersigmoid,   476 

- interstitial,   609 

■ traumatic,  611 

■  into  foramen  of   Winslow,  476 

involvement   of   appendix   in,   557 

large  scrotal,  operation  for,  621 

double-filigree,  622 

■  lateral,  operative  treatment  of,  631 

Littre's,   612 

■  lumbar,    605 

operative  treatment   of,    632 

by  filigree,  632 

Meckel's  diverticulum  and,  445 

obturator,   606 

strangulated,      treatment      of, 

650 

of  appendix,  476 

of  bladder.  614,   856 

of  cecum,    613 

of  Meckel's   diverticulum,    612 

of  sigmoid,    613 

of  stomach,    319 

pericecal,   476 

r  perineal,  608 

,  operative  treatment  of,  634 

by   "  spider-web  "  fili- 
gree,   634 

postoperative  complications  of,  634 

■  recurrence  of,   after  operation,   637 

reduction   of,   615 

retroperitoneal,  474 

Richter's,    607,    612 

— — ■  sciatic,  607 

. operative  treatment  of,  633 

strangulated,     treatment      of, 

650 
spontaneous,   604 

strangulated,   591,  639 

.  after-treatment   of,    654 

causes  of,  641 

pathology  of,   642 

prognosis   in.    656 

retrograde,    641 

stricture     of     intestine    after 

523 

symptoms  of,   640 

. treatment  of,   644 

.  by   fecal   fistula.   651 

. bv    intestinal    fistula,    651 

. . by  kelotomy,  648 

. after  -  complications 

of.    655 

by   taxis,    644 

• operative,   648 

choice    between     me- 
thods of,  652 


INDEX   TO  VOL.   II 


1093 


Hernia,  strangulated.  1  reatment  of,  oper- 
ative, reooverability  <>r  bowel 

in.  650 

untreated,   prognosis   In,   642 

varieties  of,  64 1 

structure  >>i.  580 

theory  of,  congenital,  590 

through   acar   tisBue,  604 

treatment   of,  614 

in   infancy,  614 

in    old   asi',   615 

in   young  adults,  614 

operative,  618 

indications  for,  618 

palliative,   615 

by   manipulation,  615 

■ bv  truss,   616 

umbilical,   599 

causes  of,   600 

olinical  features  of,  600 

congenital,  603 

operative  treat  incut   of,  628 

. — ■  by   filigree,   628 

. strangulated,   644 

. .  treatment   of,   650 

ventral,  603 

operative    treatment    of,    630 

— —  without  sac,  613 
Hernial   sac,    580 

acute   inflammation   of,   587 

adhesions  in,  588 

congenital,   581 

encysted  infantile,  582 

infantile,   582 

contents   of,    583 

diagnosis   of,   584 

secondary  changes  in,  587 

coverings  of,   585 

. ■ secondary   changes   in,  587 

- —   degeneration  of,  586 

hydrocele   of,    586 

. intrafunicular,   583 

localized  disease  of,  587 

loculation  of.  587 

modes  of  formation  of,  580 

obliteration   of   neck   of,   586 

retrofunicular,   583 

. . thickening  of  walls  of,  586 

Hernie  en  glissade,  613 
Herniotomy,   648 
Heroes   of    tongue,    180 

of  vulva,   987 

progenitalis.   978 

Herpetic   ulcers  of  tongue,   185 
Hind-gut,    665 

Hirschsprung's   disease,    446 
Horns   of   penis.    975 

Hour-glass  stomach  (see  Stomach,  hour- 
glass) 
Hydatid   cysts    (see   Cysts,   hydatid) 
Hydrocele,   bilocular,   956 

congenital,    957 

diffuse,   of   cord,   957 

• encysted,  of  cord,   957 

infantile,   9t>5 

of  canal  of  Nuck.  990 

of  hernial   sac.    586 

primary,    952 

of  tunica   vaginalis,  952 

. complications  of.   954 

. ■  pathological       anato- 
my of,   952 

-  symptoms  of,   953 

treatment  of,  954 

secondary,   951 

Hydro-hsematosalpins,  1048 
Hydronephrosis,   813 

congenital,   814 

diagnosis  of,  817 

due  to  ureteral  obstruction,  813 

due  to  urethral  obstruction,  814 


Hydronephrosis,  etiology  of,  813 

pathological  anatomy  <>t.  815 

pathology  of,  814 

■    - —  prognosis  in.  817 

I    symptoms  of,  816 

I i  real  ment  of,  81/ 

I    tuberculous,  828 

Hydrosalpinx,  acute,  1048 
1  hronio,  1049 

Hymen,  impel  forate,  991 

Hyperalgesia,  cutaneous,  433 

muscular,  433 

Hypernephroma,  820 

Hyperplasia  of  breast.  8 

Hypertrophic    Btenosis,    congenital    (see 

Pylorus,  infantile  stenosis  of) 
Hyperl  rophy  of  breast,  8 

of  endometrium,  1016 

of  spleen.  110,  113 

Hypospadias,  966 

glandis,  966 

penis,  966 

perinealis,  966 

Hysterectomy  in  myoma  of  uterus,  1043 

vaginal,  in  cervical  carcinoma,  1022 

Hystero-vaginectomy.   abdominal,   1024 

paravaginal,   1023 

total,     in     malignant     tumours    of 

vagina,  997 

Ichthyosis  of  tongue,   180 
Idiopathic   dilatation   of  colon,  446 
[leo-csecal  sphincter,  428 

tuberculosis,  :>12 

valve,   innervation  of,   431 

surgical  anatomy  of,  423 

volvulus  of,  498 

Ileum,   enteroliths  in,   502 

tuberculous  ulceration  of,  511 

Ileus,  gall-stone,  499 

paralytic,   after  kelotomy,  656 

complicating   hernia,  637 

■  verminosus.    502 

Imperforate  vagina,   991 
Impotence,  981 

nervous,  983 

paralytic,   983 

■ physical.  981 

psychical.  982 

Incarcerated  hernia.  591 
Incontinence    of    urine    (see    Urine,    in- 
continence of) 

Indican    in    urine,    in    acute    intestinal 

obstruction,    467 
Indigo-carmine  solution  test,  779 
Infarcts,   splenic,   115 
Inguinal  hernia    (see   Hernia,    inguinal) 
Inspection   of  abdomen,   437 

of  oesophagus,  255 

Intermaxillary  cleft,  146 
Intersigmoid  hernia,  476 
Interstitial   hernia.   609 

traumatic,   611 

Iutervesico-vaginal   fixation   in  prolapse 

of  uterus,  1003 
Intestinal  bacteria,  436 
■ calculi,  501 

contents,  vomiting  of,   427 

obstruction,    463 

acute,   464 

collapse  in,  467 

diagnosis  of  site  of,  469 

differential    diagnosis    of, 

468 

distension  in,  464 

exploratory      laparotomy 

in.  469 

indican  in  urine  in.  467 

morbid   anatomy   of,   464 

pain  in,  466 

pathology  of,  464 


io94 


INDEX   TO   VOL.   II 


Intestinal  obstruction,  acute,  shock  in, 
467 

■ ■ treatment  of,  469. 

•  tympanites  in,  467 

— vomiting  in,  466 

after  gastrojejunostomy,  417 

appenuix  aim,  55/ 

chronic,  470 

• clinical  features  of,  471 

■ ■ ■  diagnosis   of,   473 

effects    of,    on    mesentery, 

471 

pathology   of,   470 

terminating  acutely,  474 

■ complicating  hernia,   635 

enterospasm  and,   507 

■ from  enteroliths,  501 

from  faecal  accumulations,  502 

from  gall-stone  disease,  499,  752 

from  intussusception,  484 

■ from  kinking  of  bowel,  479 

■ ■ from  mesenteric       thrombosis, 

506 

from  peritoneal  adhesions.  478 

from  retroperitoneal      hernia, 

474 

from  strangulation,  480 

■ from  volviuus,  494 

• ■  paralytic,   463 

peritonitis  and,   571 

postoperative,   504 

reflexes,  434 

Intestine  in  hernial  sacs,  584,  588 

large    (see   Colon;    Caecum;    Appen- 

dix; Intestines) 

recoverability  of,   in  operation   for 

strangulated  hernia,  650 

small,  anatomy  of,  422 

antiperistalsis  of,  427 

carcinoma  of,  525 

constrictions     and     occlusions 

of,  congenital,  440 

diverticula  of,  440 

innervation  of,  430 

movements  of,  426 

■  peristalsis  of,   427 

■ rhythmic  segmentation  of,  426 

rupture   of,    457 

sarcoma  of,  526 

— —  tumours  of,   524 

■  volvulus  of,  498 

Intestines,  actinomycosis  of,  514 

anatomy  of,  422 

• and  referred  pain,  432 

development   of,   439 

excretory  function   of,   435 

foreign  bodies  in,  462 

inflammatory  affections  of,  508 

injuries  of,   456 

innervation  of,   430 

lymphatics  of,  424 

malformations  of.  439 

muscular  rigidity  and,  433 

physiology  of,  424 

rupture  of,   456 

secretory  and  absorptive  functions 

of,  425 

sensibility  of,  431 

strangulation  of,  by   appendix  epi- 

ploica,  482 

■ vermiformis,  482 

by  bands,  480 

by  Fallopian  tube,  482 

■ by  pedicle  of  fibroid,  482 

of  ovarian  cyst,  482 

through    abnormal    apertures, 

482 

stricture  of,  522 

tuberculous,  511 

■ ■  tuberculosis  of.  510 

tumours  of.  524 


Intestines,  ulceration  in,  517 

wounds  of,  gunshot.  460 

■ pistoi-snot,   461 

stab,  459 

lntramammary   abscess,   17 
Intraperitoneal  haemorrhage.  563 

suppuration,  localized,  572 

intussusception,  484 

acute,  in  adult,  492 

■ in  child,  485 

caecal,  4t6 

chronic,  in  adult,  492 

■ in  chilu,  491 

■  colic,  485 

enteric,   485 

entero-colic,  485 

from  carcinoma  of  colon,  535 

ileo-caecal,  4t6 

ileo-colic,   486 

involvement  of  appendix  in,  557 

Meckel's  diverticulum  and,  444 

multiple,  too 

Inversion  of  bladder,   856 

of  uterus,  100/ 

Iodipin   test  for  gastric  acidity,  309 
Ionization    isce    Cataphoresis) 
Ischio-rectal   abscess,   btit> 

fossa,   665 

Jaundice  in  carcinoma  of  stomach,  386 

in  aisease    of    stomach   and    duode- 

num,   305 

in  duodenal  ulcer,  364 

in  gall-stone  disease,  752 

Jejunal  ulcer,   517 
Jejunostomy,   418 

in  carcinoma  of  stomach,  391 

Kelotomy  in  strangulated  hernia,  648 

after  -  complications     of, 

655 
Kidney,  absence  of,  congenital,  789 

actinomycosis  of,  832 

anatomy  of,  777 

atrophy  of,  congenital,  789 

bilharziosis  of,  832 

carcinoma  of,  819 

congenital  abnormalities  of,  789 

cysts  of,  824 

hydatid.  825 

solitary,  825 

examination  of,  780 

exploration  of,  781 

■  floating,  791 

■  horse-shoe,  789 

■  hypernephroma,  820 

injuries   of,   with   external    wound, 

797 
without  external  wound,  795 

lymphatics  of.  778 

misplacement  of,  fixed,  790 

■  movable,  791 

as    cause    of    hydronephrosis. 

814,  817 

clinical  features  of,  791 

■  diagnosis  of,  794 

Dietl's  crises  in,  793 

etiology  of,  791 

■  pathological  anatomy  of,  791 

treatment  of,  operative,  795 

palliative.  795 

■  polycystic,  824 

sarcoma  of.  819 

solitary,  789 

stone  in  (see  Eenal  calculus) 

surgical  inflammations  of,  801 

syphilis  of,  831 

tuberculosis  of,  827 

diagnosis  of.  829 

etiology  of.  828 


[NDEX   TO   VOL.   II 


Kidney,  tuberoulosis  of,  method  of  In- 
fection in.  828 

pathological  anatomy  of,  828 

prognosis  in,  829 

symptom-  of,  829 

— : treatment  of,  830 

uloero-cavernous,  82C 

tumour-  of,  benign.  818 

malignant,  818 

diagnosis  of.  822 

etiology  of,  818 

• extension  of.  820 

histology  of,  819 

metastases    of,    820 

pathology  of.  819 

prognosis  in,  822 

symptoms  of,  820 

treatment  of.  822 

mixed,  820 

(see  also  Renal) 

Kidneys,  fused.  789 

Killian's  cesophagoscopy.  258 

Kinking    of    intestine    in    carcinoma   of 

colon,  535 

obstruction  from.  479 

Kocher's  operation  for  inguinal  hernia, 

619 

for  lingual  carcinoma,  223 

Kraurosis  vulvae.  989 

Labia,  cysts  of.  990 

Lane's    lArbuthnot)    operation    for   cleft 

palate.  153 
Langenbeck's  operation  for  cleft  palate, 

159 
Laparotomy,  469.  858,  859 
•  Leather-bottle  "    stomach,  380 
Leucocytosis  after  splenectomy,  103 
Leucokeratosis  of  tongue,  180 
Leucoplakia  of  tongue,  186 
Leucoplakic  vulvitis.  988 
Leucorrhoea,   1084 

in  chronic  endocervicitis.  1014 

Leukaemia,  splenic,  113 

Levator  ani,  661 

Ligamentopexv   in    retroversion   of   ute- 
rus. 1006 
Lingual  abscess,  176 

cancer  (see  Tongue,  carcinoma  of) 

tonsil,  inflammation  of,  175 

Linitia,  plastic,  398 

suppurative,  399 

Lipoma  of  breast,  49 

of  rectum.  714 

of  small  intestine.   525 

of  stomach.  376 

Lips,  development  of,  121 

fistula  of,   128 

malformations   of,  121.   126 

Liquefaction  in  breast  carcinoma,   70 
Lithiasis  (see  Calculi) 
Litholapaxy,  875 

Lithotomy,   median    perineal,  876 

suprapubic.  876 

vaginal.  876 

Lithotrity.  875 
Littre's  hernia.  612 
Liver,   abscess  of,  733 

■ anatomy  of.  729 

angioma  of,  737 

— — -  carcinoma  of.  738 

cirrhosis  of.  736 

cysts  of,  738 

ducts  of.  730 

injuries  of,  731 

malformations    and    misplacements 

of.  731 
■  movable,  731 

sarcoma  of,  738 

syphilis  of,  736 

tubenul  i-i-  of,  736 


Lumbar  bernia  {tee  Bernia,  lumbar) 
Lupoid  ulcer  of  tongue,  189 
Lutein  oj  s1  -.  1067 
Luye    separator,  847 
Lymph-scrotum,  981 
Lymphadeno-aarooma  "i   stomach,  395 
Lymphangioplasty  for  brawny  arm.  95 
Lymphatic    arrangements    ol     -Km    ol 
breast,  5 

comnitmi'  -at  inn  between  mammae,  5 

invasion  in  carcinoma  ol  Btomach, 

381 

oedema  of  arm   (see   Brawny  arm) 

Bpread    of    carcinoma    <>t     rectum, 
717 

of  stomaoh,  381 

Lymphatics  of  appendix,  538 

of  bladder,  846 

of  breast,  3 

of  intestines,  424 

of  kidney,  778 

of  peritoneum.  560 

of  rectum,  717 

of  stomach.  300 

of  tongue,  165 

of  urethra.  883 

Lymphocytosis  after  splenectomy,  103 
Lympho-sarcoma  of  stomach,  394 

of  testis,  944 

McBurney's  "  gridiron  "  incision  in 
appendicectomy,  554 

Macewen's  operation  for  inguinal  her- 
nia, 619 

MeGavin's  double-filigree  method,  622 

modification   of   Bartlett's    method. 

629 
Macroglossia,  199 

inflammatory,  202 

lymphangiomatous,   199 

■ ■  mercurial.  202 

muscular,  201 

syphilitic,  194 

Macrostoroa,  126 
Malarial  spleen.  110 
Male  genital  tract,  907 
Malformation  of  bile-ducts,  740 

of  face,  121,  126 

of  intestines,  439 

■  of  lips,  121.  125 

of  liver,  731 

of  oesophagus,  259 

of  palate,  121,  144 

of  rectum  and  anal  canal,  665 

— -  symptoms  of,  670 

■ treatment  of.   670 

of  stomach  and  duodenum,  311 

of  tongue,  167 

of  urethra,  885 

Mamma   (see  Breast) 

Mammas,  lymphatic  communication  be- 
tween, 5 
Mammary  abscess,  acute,  16 
Mandibular  cleft.  128 
Mastitis,  acute,  14 

Bier's  treatment  in,   18 

•  symptoms  of,  16 

treatment  of,   16 

vaccine  treatment  of.  18 

adolescentium,  6 

carcinomatosa,  80 

chronic.  19 

and  fibro-adenoma,  23 

as  precursor  of  carcinoma,  50 

atrophic.  20 

diagnosis  of.  24 

■ from  carcinoma,  76 

etiology  of,  19 

hypertrophic,   20 

in  duct  papilloma,  23 

pathology  of.  19 


1096 


INDEX  TO   VOL.   II 


Mastitis,   chronic,   prognosis   in,   24 

symptoms  of,  21 

■ treatment  of.  24 

by  X-rays,  26 

gummatous,     diagnosis     of     carci- 

noma from,  77 

neonatorum,  6 

tuberculous,  26 

diagnosis   of  carcinoma  from, 

77 
Maxillary  arch,  rectification  of,  141 
Meckel's   diverticulum,   441 

complications   of,   443 

hernia   of,    612 

in  hernial  sacs,  584 

varieties   of,   442 

Medullary  carcinoma  of  breast,  78 
Menorrhagia,   1084 
Mercurial  ulcers  of  tongue,  187 
Mesenteric  cysts   of   peritoneum,   579 
Mesentery,   anatomy  of,  422 

injuries  of,  461 

striation   of,   in   chronic   intestinal 

obstruction,   471 
Methylene-blue   test.   779 
Metritis,  fibrotic,   1016 
Metrorrhagia,   1084 
Microstoma,  127 
Mikulicz's    disease    of    salivary    glands, 

245 
Milk   engorgement,   14 
Mirault's  operation  for  single  hare-lip, 

Moc-main  truss,  617 

Mole,   tubal,   1056 

Monorchism,  924 

Morgagni,   columns    of,  660 

Mouth,  floor  of,  234 

Movable  kidney  (see  Kidney,  movable) 

liver,  731 

epleen,  109 

Mucous  cysts  of  tongue,  199 
Muscular  hyperalgesia,  433 
Myoma  of   small  intestine.  525 

of  stomach   and  duodenum,  375 

of  testis,   942 

of  uterus  (see  Uterus,  myoma  of) 

of   vagina,    997 

Myomectomy,    abdominal,    1042 

vaginal,    1042 

Myorrhaphy  in  prolapse  of  uterus,  1003 
Myxo-fibroma.  subperitoneal,  simulating 

hernia,  608 
Myxoma  of  breast,  49 
Myxomatoid  degeneration  in  myoma  of 

uterus,  1034 

Naevi  of  tongue.  202 

Naevoid  degeneration  in  myoma  of 
uterus,   1034 

Necrotic  changes  in  breast  carcinoma,  70 

Nelaton's  operation  for  single  hare- 
lip, 138 

Neoplasms  (see  Tumours) 

Nephrectomy  in  hydronephrosis,  818 

in  perinephric  abscess,  801 

in  pyelitis  of  pregnancy,  809 

in  pyelonephritis,  805 

in  pyonephrosis,  811 

in  renal  calculus,  837 

fistula?,  813 

injuries,  797 

tuberculosis.  830 

in  tumours  of  kidney,  822 

of  renal  pelvis  and  ureter,  823 

of  suprarenal  eland.  827 

Nephritis,  non-suppurative,  813 
Nephrolithotomy,  836 
Nephropexy,  795 
Nephrostomy   in   renal  fistulae,   812 

in  vesical  carcinoma,  872 


Nephrotomy  in  calculous  anuria,  839 

in  hsematuria,  787 

in  pyelitis  of  childhood,  808 

of  pregnancy,  809 

in  pyelonephritis,  805 

in  pyonephrosis,  811 

in  renal  tuberculosis,  831 

Nerve  injuries,  effect  of,  on  bladder,  881 
Nervous      diseases,      influence     of,      on 

bladder,  880 
Neuralgia  of  testis,  948 
Neuroses  of  prostate,  921 
New  growths  (see  Tumours) 
Nigrities,  184 
Nipple,  carcinoma  of,  10 
■  chancre  of,  13 

"  cracked,"  9 

diseases  of,  8 

eczema  of,  9 

Paget's  disease  of,  10 

papilloma  of,  9 

retraction  of,  8 

■ and    elevation    of,    74 

serous  discharge  from,  10 

Nocturnal  emissions,  950 

enuresis,  849 

Noma  vulvae,  986 

Nutrient  enemata,  absorption  of,  430 

Obstruction,    intestinal    (see    Intestinal 
obstruction) 

oesophageal,   274 

Obturator  hernia  (see  Hernia,  obtu- 
rator) 

Occlusion  of  duodenum,  312 

(Edematous  degeneration  in  myoma 
of  uterus,  1034 

(Esophagectomy,  cervical,  289 

thoracic,  290 

(Esophago-gastrostomy,  290 
OSsophagoscopy,  258 

in  carcinoma,  289 

in  foreign  bodies,  269 

in  obstruction,  283 

OZsophago-spa^m,    274 
QCsophagostomy,  cervical,  292 
QSsophagotomy  in  stricture,  282 

mediastinal,  273 

(Esophagus,  anatomy  of,  253 

atresia  of,  congenital,  259 

carcinoma  of,  283 

age-   and   sex-incidence  of,   2£6 

■ diagnosis  of,  288 

distribution  of,  286 

— — - symptoms  of,  287 

: —  treatment  of.  289 

dilatation   of.    in   fibrous   stricture, 

279 
in  malignant  stricture,  291 

diverticula  of,  260 

pressure,  261 

traction,  263 

traction-pressure,  263 

treatment  of.  264 

examination  of,  255 

fibrous  stricture  of,  277 

foreign  bodies  in,  267 

complications  of,  268 

diagnosis  of.  269 

■ extraction  of,  270 

symptoms  of.  267 

treatment  of,  270 

— —  injuries  of.  266 

malformations  of,  259 

obstruction   of.   extrinsic,   295 

intrinsic,  274 

operations  for  exposure  of.  254 

permanent  intubation  of,  in  carci- 

noma, 291 

rupture  of.  265 

sarcoma  of,  294 


INDEX   TO   VOL    II 


[097 


(Esophagus,    spasm   of   muscle   coat   of 
274 

stenosis  of,  260 

tumours  of,  283 

wounds  of.  26o 

Oligospermia,    9  11 
Oliguria,  781 

ill    renal    OalCUlUS,   844 

Omentopexy   for  cirrhotic  liver,  736 
Omentum  in  hernia]  sacs,  583,  587 
Oophorectomy  in  inoperable  carcinoma    ' 

of  breast.  94 
Oophoritis,  1064 
Oophoronio  cysts,  1067 
Open-air  treatment  in  inoperable  breast 

carcinoma,  94 
Oppler-Boas  bacillus,  311 
Orchidectomy  in  carcinoma  of  scrotum, 
980 

in  hoematocele  of  tunica  vaginalis, 

961 

in  imperfect  descent,  927 

in  neuralgia  of  testis,  949 

in  tuberculous  epididymo  -  orchitis, 

938 
Orchidopexy  in  imperfect  descent,  926 
Orchitis,  933 

and  rheumatism,   934 

complicating  hernia,  637 

epididymo-  (see  Epididymo-orchitis) 

gouty,  933 

of  epidemic  parotitis,  933 

of  influenza,  934 

of  malaria,  934 

of  scarlet  fever,  934 

of  smallpox,  934 

of  typhoid  fever,  934 

Osteoma  of  testis,  941 
Ovarian  cachexia,  1074 

cysts,  1065 

malignant      degeneration      of, 

1075 

dysmenorrhcea,  1083 

gestation,   1065 

Ovariotomy,  1077 
Ovary,  absence  of,  1064 

accessory,   1064 

adenoma  of,  1078 

carcinoma  of,  1079 

cyst-adenomas   of,   1067 

cysts  of  (broad  ligament),   1069 

diagnosis  of,  1076 

follicular,  1067 

(lutein),  1067 

malignant,  1072 

(oophoronic),   1067 

papuliferous,   1072 

(paroophoronic).  1069 

— —  (parovarian),  1070 

symptoms  of,  1074 

teratomatous.  1068 

■  treatment  of,  1077 

(tubal),   1071 

fibroma  of,  1078 

in  hernial  sacs,  584.  589 

■  inflammation  of,  1064 

papilloma  of,  1078 

prolapse  of,   1064 

Owen's  operation  for  single  hare-lip,  140 

Paederasty,  982 

Paget's  disease  of  nipple.  10 

diagnosis   of,   13 

histological     appearances 

of,  11 

■ pathology   of.   12 

prognosis  in.   13 

treatment  of,  13 

Palate,  bipartite,  145 

cleft,  144 

after-treatment  of,  161 

3  ;-  * 


Palate,  oleft,  early  operations   for,  151 

late  operation  for,  159 

operation   lor.  149 

best  age  for,  149 

Brophy'e,  151 

Lane's  (Arbuthnot),  153 

Langenbeek's,  159 

symptoms  of,  147 

treatment  of,   149 

varieties  of,  144 

development  of,  124 

mallei  niaiioris  of.   121,   144 

tripartite,  144 

Palpation  of  abdomen,  437 

of  kidney,  780 

of  oesophagus,  255 

Pancreas,  abnormalities  of,  763 

anatomy  of,  763 

calculi  of,  775 

carcinoma  of,  774 

congenital  cystic  disease  of,  771 

cysts  of,  pseudo-,  771 

true,  770 

fistula  of.  775 

injuries  of,  764 

interacinous  cysts  of,  771 

syphilis  of,  770 

■  tuberculosis  of,  770 

Pancreatitis,  764 

acute,  diagnosis  of,  767 

— — ■  morbid  anatomy   of,  765 

prognosis  in,  767 

symptoms  of,  766 

■ ■  treatment  of,  767 

and  duodenal  ulcer,  364 

catarrhal,  symptoms  of,  766 

chronic,  768 

■  morbid  anatomy  of,  766 

prognosis  in,  769 

symptoms  of,  769 

treatment  of,  769 

etiology  of,  764 

fat  necrosis  in,  765 

haemorrhage  in,  765 

Papillary  cyst-adenoma  of  breast,  46 
Papilloma  of  anal  canal,  714 

of  bladder,  866 

of  nipple,  9 

of  ovary,  1078 

of  penis,  974 

■  of  rectum,  713 

of  tongue,  203 

of  urethra,  900 

of  vagina,  997 

of  vulva,  987,  990 

Paralytic   ileus  after  kelotomy,  656 

complicating  hernia,  637 

Parametritis,  1080 
Paraphimosis,  972 
Parasitic  cysts  of  tongue,  199 
Paroophoronic  cysts,  1069 
Parotid  duct,  injuries  of.  235 

gland,  injuries  of,  234 

Parotitis,  epidemic,  240 
Parovarian  cysts,   1070 

"  Peau  d'orange,"  65 
Pelvic  cellulitis,  1052 

colon  (see  Colon,  pelvic) 

peritonitis,  1080 

Pelvi-rectal  abscess,  686 
Pelvis,  renal  (sec  Renal  pelvis) 
Penis,  absence  of,  congenital.  965 

carcinoma  of,  975 

congenital  abnormalities  of,  965 

constriction  of,  974 

contusion  of.  973 

dislocation  of,  973 

double,  965 

fracture  of.  973 

■  herpes  of,  978 

horns  of.  975 


1098 


INDEX  TO   VOL.  II 


Penis,  papilloma  of,  974 
■ — —  sarcoma  of,  978 

■ tuberculosis  of,  902 

tumours  of,  innocent,  974 

malignant,  975 

■  webbed,  965 

Peptic   jejunal   ulcer    following   gastro- 
jejunostomy, 415 

ulcers,  340,  342 

following    gastroenterostomy, 

517 
Percussion  of  abdomen,  438 

of  kidney,  780 

of  oesophagus.  256 

Perforation  of  gastric  ulcer  (see  Gastric 
ulcer,  perforation  of) 

typhoid,  518 

Perianal  skin,  redundant  folds  of,  674 

soft  chancre,  698 

Pericecal  hernia,  476 
Pericolitis,  510 
Pericystitis,  877 
Perigastric  abscess,  373 
Perigastritis,  358 

Perilymphatic    fibrosis    and    dissemina- 
tion of  breast  carcinoma,  60 
Perimetritis,  1080 

Perineal  hernia  (see  Hernia,  perineal) 
Perineoplasty  and  colporrhaphy  in  pro- 
lapse of  uterus,  1003 

and  ventro-suspension  in   prolapse 

of  uterus,  1003 

in  cystocele,  994 

in  prolapse  of  uterus,  1003 

Perinephritic  abscess,  799 
Perinephritis,  798 

Peripheral  carcinoma  of  breast,  80 
Perirenal  fascia,  777 

fistulas,  812 

tumours,  826 

Peristalsis  of  small  intestine,  427 
Peritoneal  adhesions  and  intestinal  ob- 
struction, 478 

haemorrhage,  563 

watersheds,  559 

Peritoneum,  absorptive  powers  of,   561 

anatomy  of,  558 

ascites  and,  579 

compartments  of,  558 

■  contusions  of,  562 

defences  of,  against  bacterial  infec- 

tion, 562 

diseases  of,  564 

downward  displacement  of,  581 

hydatid  cysts  of,  578 

infection  of,  in  carcinoma  of  colon, 

535 

injuries  of,  562 

lymphatics  of,  560 

mesenteric  cysts  of,  579 

nerves  of,  561 

physiology  of.  561 

pouches  of.  558 

secondary    collateral    changes    in, 

1074 

sensibility  of,  431 

subphrenic  region  of,  560 

tumours  of,  578 

wounds  of,  562 

Peritonitis,  acute  diffuse.  564 

after-treatment  of,  570 

complications   of,   571 

diagnosis  of.  568 

symptoms  of,  567 

treatment  of,  569 

gonococcal,  567 

pneumococcal,  566 

streptococcal.  566 

after  kelotomy,  656 

chronic  gonococcal.  575 

pneumococcal,  576 


Peritonitis,  chronic  septic,  575 

colon  bacillus,  565 

diffuse,     from    acute    appendicitis. 

547,  550 
pelvic,  1080 

tuberculous,  576 

Peritubal  haematocele.  1056 
Periurethral  abscess,  897 
Periurethritis,  897 

chronic  indurative,  898 

diffuse  phlegmonous,  898 

Perivesical  abscess.  877 

hydatid  cysts,  857 

Permeation  theory  of  dissemination  of 

breast  carcinoma,  60 
Pessaries  in  prolapse  of  uterus,  1002 

in  retroversion  of  uterus.  1005 

Phagedaenic  vulvitis,  986 
Phenol-sulphone-phthalein  test,  779 
Phimosis,  970 

acquired,  971 

congenital,   970 

Phlegmonous  gastritis,  399 
Phloridzin  test,  779 

"  Pig-skin,"  65 
Pile,  sentinel,  683 

true  external,  675 

Piles,  672 

after-treatment  of.  680 

■  cutaneous,  674 

diagnosis  of,  67? 

■  etiology  of,  672 

external,  673 

■  internal,  675 

postoperative  complications  of.  680 

■  recurrence  of,  682 

■  symptoms  of,  676 

thrombotic,  674 

■ ■  treatment    of.   by   clamp    and   cau- 
tery, 678 

bv  individual  excision,  679 

by  ligature,  678 

by  Whitehead's  operation.  680 

palliative,  677 

Pistol-shot  wounds  of  intestines,  461 

Plastic  linitis,  398 

Pneumaturia.  788 

Pneumococcal  peritonitis,  acute,  566 

chronic.  576 

vaginitis,   995 

vulvitis,  986 

Polymastia,  7 
Polyorchism,  924 

Polypi,  mucous,  of  stomach,  377 

of  cervix  uteri,  1017 

of  oesophagus,  283 

of  urethra,  900 

of  uterus,  1046 

Polyuria,  781 

in  renal  calculus,  835 

Postallantoic  eut.  666 

abnormalities  of,  668 

Premaxilla,  development  of,  125 

replacement  of,  142 

Premaxillary  clefts,  146 
Prepuce,  calculi  under,  973 

fraenum  of,  rupture  of,  973 

shortness  of.  973 

(see  also  Phimosis) 

Priapism,  979 
Proctitis,  693 

catarrhal,  694 

diffuse  septic,  694 

gangrenous,  694 

gonorrhceal,  694 

Proctodeum,  666 

abnormalities  of,  669 

Proctotomy,    complete,    in    rectal    and 

anal  stricture,  706 
Proliferous  cysts  of  breast,  46 
Proportional  renal  mensuration,  817 


1NDKX    TO    VOL.    II 


1099 


Prostate  anatomy  of,  907 

calculus  of.  908 

oaroinoma  of,  919 

etiology  of,  919 

symptom  -    of,  919 

treatment  of,  921 

enlarged,  as  oauBe  of  retention,  852 

enlargement   of,  chronic.  911 

acute    retention    of    urine 

due  to.  918 

etiology  of,  911 

examination    in,   915 

pathology  of,  911 

results  of,  912 

symptom-  of,  914 

treatment  of,  by  catheter- 
ization, 915 

general,  915 

operative,  '916 

neuroses  of,  921 

sarcoma  of,  918 

tuberculosis  of,  909 

Prostatectomy,  916,  921 

complications  of,  918 

perineal.  917 

suprapubic,  917 

Prostatitis,  acute,  908 

chronic,  908 

Pruritus  ani.  727 

vulvae,  986 

Pseudo-cysts  of  pancreas,  770,  771 
Pseudo-diDhtheria,  173 
Pseudo-hermaphrodism,  968 

external,  969 

internal,  969 

Pseudo-perforation  of  gastric  ulcer,  356 
Psoriasis  lingua?,  186 

Pyelitis,  806 

of  infancy  and  childhood,  807 

of  pregnancy,  808 

Pyelography  in  hydronephrosis,  817 
Pyelolithotomy,  837 
Pyelonephritis,  aseptic,  801 

of  pregnancy,  808 

septic,  bacteriology  of,  801 

clinical  features  of,  803 

pathology  of.  802 

primary,  802 

prognosis  in,  804 

secondary,  802 

treatment  of,  804 

Pyelotomy  in   calculous  anuria.  839 
Pylorus,  congenital  atresia  of,  311 

stenosis  of,  and  duodenal  ulcer,  364 

infantile,  314 

diagnosis  of.  315 

■  etiology  of,  314 

prognosis  in.  317 

symptoms  of,  315 

treatment  of,  318 

Pyometra,  1015 

Pyonephrosis.  809 
Pyosalpinx,  1047 
Pyuria,  787 
in  renal  calculus.  835 


Radiography  (see  X-ray  examination! 
Radium  in  carcinoma  of  oesophagus,  292 

of  salivary  glands,  248 

of  tongue.  232 

in  leucoplakia,  184 

in  pruritus  ani,  727 

Ranula,  246 

Rectal  abscess,  submucous,  686 

sinus,  691 

—  septic  ulceration  of,   698 


Rectocele,  995 
Rectopexy.  711 
Recto-urcthral   fistula, 
Recto-vaginal  fistula. 


693 
693 


Recto  ■  ula,  692 

Rectum,  abnormal  termination  of,  667 

adenoma  of,  711 

anamnesis  in  diseases  of,  664 

anatomy   of,  658 

blood    -u|ipl\    of,   663 

carcinoma  of,   715 

diagnosis    of,   720 

irremovable,  treatment  of,  725 

pathology   of.  716 

removal  of,  abdominoperineal, 

723 

spread  of,  by  blood-stream,  718 

p<  rineal,  721 

by  Lymphatics.  717 

direct,  716 

■ symptoms  of,  718 

treatmenl   of,  720 

diphtheria  of,  694 

dysentery  and,  698 

exam  inal  ion  of,  664 

fibroma  of,  714 

fistulas  of,  687 

inflammation  of   (see  Proctitis) 

lipoma  of,*  714 

malformations  of,  665 

muscles  of,  661 

papilloma  of,  713 

prolapse  of,  706 

diagnosis  of,  709 

etiology  of,  707 

symptoms  of,  708 

treatment   of,   709 

sarcoma  of,  714 

stricture  of,  704 

syphilis  of.  697 

tuberculosis  of,   695 

ulceration  of,  698 

chronic  diffuse,  699 

follicular,   699 

treatment  of,  701 

Red  degeneration  in  myoma  of  uterus, 
1034 

Reduction  of  hernia.  615 

en   masse,  644 

Referred  pain,  intestinal,  432 

Regression,  natural,  in  breast  carci- 
noma, 69 

Renal  artery,  777 

aneurysm  of,  798 

calculi,  bilateral,  837 

in  solitary  kidney,  837 

structure    and    chemical    com- 
position of,  833 

calculus,  832 

changes  in  kidney  in,  834 

course   and    complications    of, 

835 

diagnosis  of,  835 

etiology  of,  832 

symptoms  of,   834 

treatment  of,  operative,  836 

prophylactic,   836 

symptomatic,  836 

colic  in  calculus  of  kidney,  834 

of  ureter,  843 

treatment  of,  836 

failure,  signs  and  symptoms  of,  778 

fistulas,  postoperative.  812 

spontaneous,  812 

function.  778 

tests  of,  779 

mensuration,  proportional,  817 

pelvis.  777 

congenital     abnormalities     of, 

790 

estimation  of  capacity  of,  817 

surgical  inflammations  of,  801 

tumours  of.  823 

(see  also  Kidney) 

Repair,  natural,  in  breast  carcinoma,  69 


INDEX   TO   VOL.  II 


Resection  in  vesical  carcinoma,  870 
Retention  of  urine  {see  Urine,  retention 

of) 
Retromammary  abscess,  17 
Retroperitoneal  hemorrhage,  563 

hernia,  474 

invasion     of    abdomen     in     breast 

carcinoma.  63 
Rhabdo-myo-sarcoina  of  kidney,  820 
Rhythmic  segmentation,  426 
Richter's  hernia,  607,  612 
•'  Riedel's  lobe,"  731 
Rigidity,    localized,    in   gastric    disease, 

304 
Rodman's  operation.  406 
Rontgen  rays  (see  X-rays) 
Rose's  operation  for  double  hare-lip,  143 

for  single  hare-lip,  138 

Eoux's  operation,  410 

Sac,  hernial   (see  Hernial  sac) 
"  Saddle  "  ulcers,  344 
Sahli's  "  desmoid  "  test,  310 
Salivary  calculi.  243 

ducts,  cysts  of,  245 

fistulae  of,  237 

inflammation  of,  242 

glands,  actinomycosis  of,  244 

adeno-carcinoma  of,   248 

— ■  adenoma  of,  248 

carcinoma  of,  248 

cysts  of,  246 

diseases  of,  239 

fistula?  of,  236 

infective  granulomata  of,  244 

—  inflammation     of     (see     Sial- 
adenitis) 

■  injuries  of,  234 

Mikulicz's  disease  of,  245 

ranula  and,  246 

■  sarcoma  of,  248 

scirrhus  of,  248 

syphilis  of,  245 

tuberculosis  of,  244 

■  tumours  of,  247 

Salpingectomy,  1054 
Salpingitis,  1047 

acute,  clinical  features  of,  1050 

diagnosis  of,  1051 

non-suppurative,  pathology  of, 

1048 

pathology  of,  1047 

suppurative,  pathology  of,  1047 

treatment  of,   1053 

chronic,  clinical  features  of,  1051 

diagnosis  of,  1052 

fibrotic,  1049 

pathology  of.  1048 

treatment  of,  1054 

prognosis  in,  1053 

Salpingo-oophorectomy,  1054 
Salpingostomy,  1054 
Sarcinse,  311 

Sarcoma  of  bladder,  872 

of  breast  (see  Breast,  sarcoma  of 

of  colon,  536 

of  duodenum.  396 

of  kidnev,  819 

of  liver.  738 

of  oesophagus,  294 

of  penis,  978 

of  prostate,  918 

of  rectum.  714 

of  salivary  glands,  248 

■  of  scrotum,  980 

of  small  intestine,  526 

of  spleen,  118 

of  stomach  (see  Stomach,  sarcoma 

of) 

of  testis,  944 

of  tongue,  204 


Sarcoma  of  uterus,  1045 

of  vagina,  997 

of  vulva,  991 

Sarcomatous  degeneration  of  myoma  of 

uterus,  1034 
Scalds  and  burns  of  tongue,  171 

tic  hernia  (see  Hernia,  sciatic) 
Scirrhus  of  breast,  atrophic,  79 

of  colon,  528 

of  salivary  glands,  248 

Scrotal  hernia  (see  Hernia,  scrotal i 
Scrotum,  acute  septic  infection  of,  979 

carcinoma  of,  980 

elephantiasis  of,  981 

melanotic  sarcoma  of,  980 

sebaceous  cysts  of,  980 

tumours  of,  innocent,  981 

malignant,  980 

Segmented  stomach  (see  Stomach,  hour- 
glass) 

Semen,  nocturnal  emissions  of,  950 

"  Sentinel  pile,"  683 

Sequestration  dermoids  of  tongue,  195, 
196 

Serum  treatment  in  bacteriuria,  784 

in  cystitis,  863 

in  septic  pyelonephritis,  805 

■  of  lingual  carcinoma,  213 

Shock  in  intestinal  obstruction,  acute, 
467 

Sialo-adenitis,  240 

acute,  240 

chronic,  242 

subacute,  242 

Sialo-ductitis,  242,  243 
Sigmoid,  hernia  of,  613 
Sigmoidoscope  in  examination  of  intes- 
tines, 439 

of  rectum,  664 

Sinus,  cutaneous,  691 

rectal,  691 

septic  ulceration  of,  698 

"  Smoker's  patch,"  186 

Somatic  pain,  432 

Spermatic  cord,  hematocele  of,  961 

hydrocele  of   (see  Hydrocele) 

inflammation  of,  964 

torsion  of,  928 

acute,  928 

recurring,  929 

Spermato-cystitis,  922 
Spermatorrhoea,  so-called,   949 
Sphincter  ani,  external,  661 

internal,  660 

postoperative    loss    of   control 

of.  682 
Spider-web  filigree,  634 
Splanchnic  pain,  432 
Splanchnoptosis,  450 
Spleen,  103 

abscess  of,  113 

actinomycosis  of,  117 

anaemic,  hypertrophy  in,  111 

Banti's  disease  of,  hypertrophy  in, 

112 
cavernous  angioma  of,  118 

cysts  of,  118 

ectopic,  109 

gumma  of,  118 

hydatid  cyst  of,  118 

hypertrophy  of,  idiopathic,  110 

leukemic,  113 

malarial.  111 

■  infarction  of,  115 

inflammation   of,  113 

movable,  109 

neoplasms  of.  118  . 

prolapse  of,   109 

removal  of,  effects  of,  103 

■ technique  of,   104 

rupture  of,  105 


INDEX   TO   VOL.   II 


IIOI 


Spleen,    rupture    of,    complications    of, 

108 

diagnosis    of.    105 

treatment  of,  106 

sarcoma  of,   118 

torsion  of,   110 

tuberculosis  of,  116 

wandering,   109 

Splenectomy,  103.  108,  110.  Ill,  112,  114 

Splenopexy,  109 

Stab  wounds  of  intestines,  459 

of  stomach.  335 

Staphylococcal  vaginitis,  995 

vulvitis.  986 

Stenosis  after  kelotomy,  656 

hypertrophic    (see    Pylorus,    infan- 

tile,  stenosis  of) 

of  duodenum.   312 

of  intestine,  522 

after  strangulated  hernia,  523 

cicatricial.    522 

traumatic,  522 

of  oesophagus,    260 

of  pylorus   (see   Pylorus,   infantile, 

stenosis  of) 

(see  also  Stricture) 

Stenson's  duct,  injuries  of,  235 
Stercoral  ulcers,  521 

in    chronic   intestinal   obstruc- 
tion, 471 

of  colon,  503 

Stomach,  adenomas  of,  377 

anatomy  of,  297 

bacteriology  of.  302 

blood  supply  of.  300 

carcinoma  of.  378 

adhesions   in.  381 

anaemia  in,  385 

ascites  in,  386 

columnar-celled,   380 

cylindrical-celled.  380 

diagnosis   of.   386 

encephaloid,  380 

etiology  of,  378 

exploration   in.  389 

fever  in.  386 

fistulas  in,  386 

gastric  secretion  and,  385 

ulcer   and,    379 

gastro-jejunostomy      in,      388, 

391 

gastrostomy  in,  391 

jaundice  in,   386 

■ — —  jejunostomy  in,  391 

loss  of  weight  in,  385 

lymphatic  spread  of,  381 

medullary,  380 

metastases   in,   386 

• pain  in.  384 

pathology  of,   379 

perforation  in,  386 

primary.  380 

race  and,  379 

scirrhus.    380 

■ sex-incidence  of,   378 

situation   of,   380 

■ spheroidal-celled,  380 

spread   of.  380 

symptoms  of,  383 

thrombosis  of  veins  in,  386 

treatment   of.   388 

vascular  infection  in,  383 

vomiting  in,  384 

cirrhosis  of,  398 

clinical  examination  of.   302 

contents,  acidity  of.  diminution  of, 

after       gastro-jejunostomy. 

412 

examination  of,  309 

in   sarcoma,   396 

cysts  of,  377 


Stomach,  dilatation  of.  acute,  324 

chronic,  327 

atonic,   328 

obstructive,  327 

examination   <>i    vomit 

disease  of,  appetite  in,  305 

cutaneous  hyperalgesia  in.  304 

examination  of  tsecee  in,  311 

of  vomit  in,   310 

haematemesis  in,  369 

haemorrhage  in.  305 

jaundice  in,  305 

pain   and   tenderness  in,  303 

physical  examination   in,  306 

rigidity  in,  304 

vomiting   in,  305 

displacement  of,  319 

divert  icnla  "t,  313 

examination    of.    by    illumination. 

307 

by   inflation.   308 

by  X-rays.  308 

fibromas  of.  375 

— —  fibromatosis  of.  398 

fibro-myomas  of.  375 

fistulas  of  (see  Gastric  fistulae) 

foreign  bodies  in.  337 

hernia  of,  319 

hour-glass,  321 

etiology  of,  321 

symptoms  of,   323 

treatment  of.  324 

injuries  of.  331,  339 

"  leather-bottle,"  380 

lipomas  of.  376 

lymphadeno-sarcoma  of.  395 

lymphatics  of,  300 

lympho-sarcoma  of.  394 

malformations  of,  311 

misplacements    >f.  311 

motor  power  of,  tests  for,  309 

mucous  polyni  of,  377 

myomas  of,  375 

nerves  of,  302 

operations  on,   404 

physiology  of,  297 

• ■  pyloric  end  of  (see  Pylorus) 

rupture  of.  331 

sarcoma  of,  393 

• ■  prognosis  in.  396 

symptoms  of.  395 

treatment   of,   396 

syphilis  of.  397 

■ tuberculosis  of,   396 

■ tumours  of.  benign,  375 

- — -  malignant,  378 

ulcer  of  (see  Gastric  ulcer) 

volvulus  of,  321 

wounds  of,  335 

Strangulation    of    hernia    (see    Hernia. 
strangulated) 

of  intestines  (see  Intestines,  stran- 

gulation of) 
Streptococcal  peritonitis,  acute,  566 

vaginitis,  995 

vulvitis,  986 

Stricture,  dysenteric,  519 

of  duodenum.  312 

of  intestine,  tuberculous,  511 

of  oesophagus,  260.   277 

of  rectum  and  anal  canal,  704 

of   urethra   (see  Urethra,   stricture 

of) 

(see  aUo  Stenosis) 

Subareolar  abscess.  16 

cyst,  simple,  33 

Sublingual   gland   (see  Salivary  glands) 
Submaxillary      gland       (see       Salivary 

glands) 
Submucous  gastritis,  399 
Subphrenic  abscess,  374.  572 


1I02 


INDEX  TO   VOL.  II 


Subphrenic  region  of  peritoneum,  560 
Suppuration  complicating  hernia,  636 

periurethral,  897 

Suppurative  linitis,  399 
Suprarenal  gland,  tumours  of.  826 
Suprapubic  cystotomy  in  urethral  stric- 
ture. 896 

puncture,  853 

Syme's  operation,  896 

Symonds's  feeding-tubes  in  oesophageal 

carcinoma,  291 
Syphilis  of  bile-ducts,  742 

of  bladder,  866 

of  kidney,  831 

of  liver,  736 

of  pancreas,  770 

■  of  rectum  and  anal  canal,  697 

■ of  salivary  glands,  245 

of  stomach,  397 

—  of  testis,  939 

of  tongue  (see  Tongue,  syphilis  of) 

of  vulva,  986 

Taxis  in  strangulated  hernia,  644 
Teratoma  of  testis,  944 
Teratomatous  cysts  of  ovary,  1068 
Test  meals,  309,  364 
Testis,  adenoma  of,  942 

anterior  inversion  of,  925 

arrest  of  development  of,  941 

atrophy  of,  940 

complicating  hernia,  635 

axial  rotation  of.  928 

carcinoma  of,  944 

congenital  abnormalities  of,  924 

cysts  of,  947 

dermoids  of,  945 

ectopic,  925 

endothelioma  of,  944 

fibroma  of,  941 

imperfect  descent  of,  925 

inflammation  of,  930 

injuries  of,  929 

lympho-sarcoma  of,  944 

myoma  of,  942 

neuralgia  of,  948 

osteoma  of,  941 

sarcoma  of,  944 

syphilis  of.  939 

teratoma  of,  944 

torsion  of,  complicating  hernia.  635 

tumours  of,  innocent,  941 

malignant,  942 

— —  clinical  features  of,  942 

diagnosis  of,  943 

— —  pathology  of,  944 

■  physical  signs  of,  942 

■ prognosis  in.  943 

treatment  of,  943 

wounds  of,  contused,  929 

incised,  930 

Thomas's  (Gaillard)  treatment  of  fibro- 
adenoma of  breast,  40 

Thoracic  invasion  in  breast  carcinoma, 
63 

Thoracotomy  in  oesophageal  carcinoma, 
290 

Thrombosis  of  mesenteric  blood-vessels, 
506 

Thrombotic  pile,  674 

Thyro-dermoids,  197 

Thyro-glossal  dermoids,  197 

Tongue,  162 

abnormal  fixation  of,  168 

■  abscess  of,  176 

— ' —  absence  of,  congenital,  167 
■  anatomy  of,  163 

arteries  of,  165 

bifid,  168 

black,  184 

burns  of,  171 


Tongue,  carcinoma  of.  205 

clinical  classification  of.  207 

course  of,  210 

diagnosis  of,  211 

etiology  of,  205 

fissured  form  of,  209 

glandular  infection  in,  207 

indurative  form  of,  209 

nodular  form  of,  208 

operation    for,    Kocher's    sub- 
maxillary, 223 
Cheatle's     modi- 
fication of,  223 

Clayton-Greene's 

modification  of, 
224 

Regnoli's,  226 

■ ■  removal  of  glands  in,  230 

by      block      dis- 
section, 231 

by      Butlin's 

method,  230 

■ — —  by        Maitland's 

method.  231 

Syme's,  225 

Whitehead's    intrabuccal, 

219 

operations  for,  214 

—  after-treatment  in,  227 

complications  of,  229 

extent  of,  218 

general     conclusions     re- 
garding, 231 

order      of      removal      of 

growths  and  glands  in, 
216 

preliminary    laryngotomy 

in,  214 
ligation  of  blood-ves- 
sels in,  214 

tracheotomy  in,  214 

recurrence  after,  236 

results  of,  232 

papillary  form  of,  208 

pathology  of.  207 

prognosis  in,  212 

■  situation  of,  209 

symptoms  of,  209 

treatment  of,  212 

■ by  radium,  232 

■ •  palliative,   232 

■ ulcerous  form  of,  208 

cysts  of,  dermoid,  195 

mucous,  199 

— -  parasitic,   199 

dermoids  of,  195 

sequestration,  195,  196 

■  tubulo-,  197 

development  of,  162 

■  dyspeptic,  178 

endothelioma  of,  204 

enlargement  of  {see  Macroglossia) 

examination  of,  166 

furrowed,  179 

gangrene  of,  177 

■  glands  of,  165 

hairy,  184 

■  herpes  of,  180 

■  inflammatory  diseases  of,  acute,  172 

chronic,  177 

(see  also  Glossitis) 

injuries  of,  170 

leucoplakia  of,  180 

lymphatics  of,  165 

malformations  of,  167 

muscles  of.  164 

naevi  of,  202 

nerves  of,  165 

papillomas  of,  203 

sarcoma  of.  204 

scalds  of,  171 


INDEX   TO   VOL.  II 


1 103 


breast 


Tongue,    -'ii    chancre    ol 
•  Byphilis  of,  1 91 

primai  j 

■ — . secondary,   192 

terl  i.ny,    193 

■ tuberculosis  of,  188 

■  tumours  of,  ocent,  202 

malignant,  204 

ulcere  of,  184 

dyspeptic,  185 

gummatous,  19-4 

herpetic,  185 

lupoid,  189 

mercurial,  187 

simple,  184 

traumatic.   186 

-  unilateral   inflammation   of,  175 
varicose  veins  of,  203 

vascular  tumours  of,    202 

veins  of,  165 

■ wounds  of.   170 

Tongue-swallowing,  169 

Tonsil,  lingual,  iniiammation  of,  175 

Tracheoplasty  in  chronic  endocervicitis, 
1011 

Trachelorrhaphy   in  chronic  endocervi- 
citis, 1011 

Tracheo-oesophageal  fistula,  259 

Transcoelomic    implantation    in 
carcinoma,   62 

Traumatic    stricture   of   intestine,    522 

ulcers  of  tongue,   186 

Tripartite  palate,  144 
Truss,   circular   spring,    617 

disadvantages  of,   616 

india-rubber,   617 

Moc-main,  617 

rat-tail,   617 

use  of,  in  hernia,  616 

indications   for,    617 

well-fitting,  characters  of  a,   617 

woollen-skein,  617 

Tubal  abortion,   1056 

- — -  cysts,  1071 

gestation.   1055 

■ condition  of  uterus  in,   1058 

diagnosis  of,  1061 

etiology   of,    1055 

pathology  of,  1055 

■  symptoms  of,  1059 

• treatment   of,   1062 

mole,  1056 

Tuberculin  in  treatment  of  renal  tuber- 
culosis, 830 

■  of  tuberculous  cystitis,   865 

Tuberculosis  of  anal  canal,  697 

of  appendix,  557 

of  caecum,  512 

of  gall-bladder  and  bile-ducts,  741 

of  intestine,  510 

hypertrophic,  512 

ulcerative,  511 

of    kidney     (see     Kidney,     tubercu- 
losis ofi 

of  liver,  736 

of  pancreas.  770 

of  penis,  902 

of  prostate,  909 

of  rectum,  695 

ulcerative.   696 

— —  of  salivary  glands,  244 

of  spleen,  116 

■ of  stomach,  396 

of  testis,  937 

- — -  in  children,   938 

of  tongue,  188 

■  of  ureter.  827 

■  of  urethra,  902 

of  vesicular  seminales,  923 

Tuberculous  cervicitis.   1011 

cystitis,  863 


1069 


392 
1063 


Tuberi  ui. hi     endomel  ril  i-.  1015 

maatitl  Lastitis,  tuberculous) 

papilloma  "i   tongue,  189 

i"  rii 1 1-.   576 

vulvitis,  987 
Tubo  i '\  a  ria  □  a  bsceu,  1048 
Tubulo-dermoida  "i   tongue,  197 

Tumours    oi    appendix.    i)56 

of  bladder,  866 

ui  breast,  35 
of  broad  liga mint . 

"I  colon,  526 
of  duodenum,  375, 

-  of    Fallopian    1 1 1 1 ><• 

of   gall-bladder  ami   bile-ducts.  760 

oi   intestines,  524 

of   kidney.   818 

of  oesophagus,  283 

of  ova  ry.    1065 

of  pancreas.  774 

of  penis,  974 

of  peritoneum,  578 

of  prostate,  918 

Of  rectum    ami    anal   canal,   711,  714 

of  renal    pelvis   anil    Ureter,    823 

of  salivary    glands,    247 

of  scrotum,  980 

of  spleen,  118 

of  stomach,  375,  378 

of  suprarenal  gland,  826 

of  testis,  941 

of  tongue,  202,  204 

of  urethra,  900 

of  uterus,  1017 

-  of  vagina,  996 

of   vesiculse   seminales,    924 

perirenal.   826 

Tunica  albuginea,  cysts  of,  947 

■  vaginalis,   haematocele   of,   958 

hydrocele   of    [see    Hydrocele) 

Tympanites  iu  acute  intestinal  obstruc- 
tion, 467 
Typhoid  perforation,   518 

Ulcer,    cancerous,   of    breast,    98 

duodenal    (sec    Duodenal   ulcer) 

■ ■  dysenteric,    519 

gastric   (see  Gastric   ulcer) 

lingual  [see  Tongue,  ulcers  of) 

peptic,    340,    342 

■ following    gastroenterostomy, 

517 

jejunal,  following  gastro- 
jejunostomy, 415 

"  saddle,"  344 

stercoral,   521 

in    chronic   intestinal   obstruc- 
tion, 471 
of  colon,   503 

typhoid,   perforation  of,  518 

Ulceration   of   intestine,    517 

tuberculous.    511 

of  rectal  sinuses,  septic,  698 

of   rectum   and    anal   canal,   698 

treatment   of,  701 

chronic   diffuse,    699 

follicular,  699 

Ulcerative    colitis,    520 

Umbilical  hernia  (sec  Hernia,  umbilical) 
Ureter,  anatomy  of,  840 

bilharziosis  of,   832 

congenital    abnormalities    of,    789, 

790 

examination  of,   840 

fistula  of,   842 

injuries    of,   841 

prolapse  of,   840 

stone  in  (sec  Ureteral  calculus) 

■  tuberculosis    of.    827 

tumours  of.  823 

wounds   of,   841 


no4 


INDEX   TO  VOL.  II 


Ureteral  calculus,  842 

■ examination   in,   844 

symptoms   of,   843 

treatment  of,  diuretic,  845 

instrumental,    845 

operative,  845 

Ureterolithotomy,    extraperitoneal,    845 
Ureterostomy  in  vesical  carcinoma,  872 
Ureterotomy  in  calculous  anuria,  839 
Urethra,  absence  of,  congenital,  885 

■ anatomy  of,  8t>2 

• congenital  malformations  of,  885 

dilatation   of,   congenital,   886 

double,   885 

female,   anatomy   of,   883 

caruncle  of,  989 

■ cysts  of,   990 

■ malignant   tumours   of,   902 

prolapse  of,    985 

male,  acquired  defects  of,  899 

■ calculus   in,    888 

cysts  of,  901 

■ ■  examination  of,  883 

■ fistula?  of,   899 

■ foreign  bodies  in,  889 

■  injuries  of,  886 

■ ■  ■ malignant   tumours   of,   901 

narrowing  of,  congenital,  886 

■ ■ rupture   of,   887 

■ stricture  of,   890 

as  cause  of  retention,  853 

■ complications  of,   893 

■  diagnosis  of,   893 

etiology   of,    890 

■ examination  of,   892 

excision  of,  897 

pathological  anatomy   of, 

890 

symptoms   of,    892 

— — ■  treatment    of,    by    dilata- 
tion, 893 

complications  of, 

895 
■ operative,  895 

obliteration  of,  congenital,  885 

papilloma  of,  900 

polypi  of,  900 

prolapse   of,    886 

prostatic,   calculi    in,    908 

tuberculosis   of,    902 

• tumours  of,   900 

Urethral  fever,   884 

shock,   884 

Urethrocele,   985 
Urethroscopy,  883 

Urethrotomy,  external,  in  stricture,  896 

for  foreign  bodies   in   urethra,    890 

■  in  urethral  calculus.  889 

internal,   in   stricture,   896 

Urinary  abscess,   897 

Urine,  changes  in,  in  chronic  pancreat- 
itis, 768 

examination  of.  779 

by   catheterization   of  ureters, 

780 
by   separators,   780 

extravasation  of,  898 

incontinence  of,   848 

—  in  childhood,  849 

mechanical,  848 

nervous,   848 

spasmodic,   849 

indican   in,   467 

•  retention  of,  851 

atonic,  851,  852 

complicating  hernia,  637 

diagnosis  of,  851 

due   to   enlarged  prostate,    918 

■ etiology   of,   851 

inbibitivc    or    spasmodic,    851, 

852 


Urine,  retention  of,  nervous,  880 

obstructive,    851,    852 

toxic,  851 

— —  treatment  of,   852 

with  enlarged  prostate,  852 

with  stricture,  853 

Uterine  fibrosis,   1016 

Uterus,   absence  of,   congenital,   997 

adeno-myoma  of,  1045 

bicornis   unicollis,    998 

body  of,  carcinoma  of,   1027 

diagnosis  of,   102ti 

etiology  of,  1027 

■ pathology   of,    1027 

■ symptoms  of,   1028 

treatment  of,  1028 

cervix  of  (see  Cervix  uteri) 

chorion-epithelioma  of,   1028 

pathology  of,    1029 

diagnosis   of,   1030 

symptoms  of,   1030 

■ ■ treatment  of,   1030 

deformities    and    displacements    of, 

997 

double,  998 

fibroids  of   (sec  Uterus,   myoma  of) 

fibro-myoma   of,   1033 

inflammation  of,  1008 

inversion  of,   1007 

myoma  of,   1030 

— -  broad-ligament,   1032 

carcinoma  and,   1035 

cervical.  1031 

corporeal,   1031 

degenerations  of,   1033 

diagnosis  of,   1040 

■ morbid  anatomy  of,   1031 

pathology    of,    1033 

physical  signs  of,   1039 

■ prognosis  in,   1041 

symptoms  of,  1035 

treatment  of,  medical,  1041 

surgical,    1042 

polypi  of,   1046 

prolapse    of,    clinical    features    of, 

1002 

■ diagnosis   of,    1002 

etiology  of,   1000 

treatment  of,   1002 

retroversion  of,  1004 

clinical  features  of,  1005 

etiology   of,    1004 

treatment  of,  1005 

sarcoma   of,   1045 

-  septus,  998 

subseptus,   998 

• unicornis,    998 

Utriculoplasty  in  fibrotic  metritis,   1017 


Vaccine  treatment  of  acute  mastitis,  19 

of  bacteriuria,  785 

of  cystitis,  863 

of  lingual  carcinoma,  213 

of  parenchymatous      glossitis, 

175 

of  prostatic   tuberculosis,   910 

of  pyelitis,  807 

of    septic    epididymo -orchitis, 

932 

of  septic  pyelonephritis,  805 

of  tuberculous  vulvitis,  987 

Vagina,  absence  of,  congenital,  992 

carcinoma  of,  997 

cysts  of,  996 

deformities   and    displacements   of, 

991 

double,  993 

fistula?  of,  993 

imperforate,  991 

inflammation  of,  995 


INDEX   TO   VOL.   II 


1105 


Vaginai  Barooma  of,  997 

septum  ni.  993 

\  alms.   951 

Vaginismus,  1082 

Qitis,  y95 
Varicocele,  962 

complicating  hernia,  635 

etiology  of,  962 

pathology  of,  963 

symptom-  of,  963 

treatment  of,  963 

\  reins  of  tongue,  203 

v. 1-0  motor  reflexes  and  intestine,  434 
\  enereal  warts.  9b7 
Ventral  hernia  (see  Hernia,  ventral) 
Ventro-suspensioii  in  prolapse  of  uterus, 
1003 

in  retroversion  of  uterus,  1006 

Vesioal  calculi,  varieties  of,  873 

calculus,  diagnosis  of,  875 

etiology  of,  872 

pathology  of,  873 

symptoms  of,  873 

treatment  of,  875 

fistula,  suprapubic,  878 

Intestinal  fistula,  879 
■  vaginal  fistula,  880 
VeeiouUe  seminales,  922 

concretions  in,  924 

cysts  of.  924 

tumours  of,  924 

Vesiculitis,  acute,  919 

chronic,  923 

gouorrhoeal,  923 

tuberculous,  923 

Viscera]   pain,  significance  of,  303 
Visceroptosis,  450 
Volvulus,  gastric.  321 

Meckel's  diverticulum  and,  444 

of  ileo-csBca]  junction,  498 

of  pelvic  colon,  494 

of  small  intestine,  498 

Vomit,   examination  of,  310 
Vomiting  in  gall-stone  disease,  752 

in  gastric  disease,  305 

ulcer,  346 

in  intestinal  obstruction,  466 

in  strangulated  hernia,  640 

of  intestinal  contents.  427 

persistent,  complicating  hernia.  635 

V  ui    Pirquet's    test,    829 

Vulva,  abscess  of,  687.  989 

carcinoma  of.  991 

chancre  of.  986 

cysts  of,  990 

deformities    and   displacements  of, 

985 

herpes  of.  987 

inflammation  of,  986 

innocent  growths  of    990 


\'ul\  a,    ki  .mi  isla   of,   989 

malignant  x\ .mih-  of,  991 

noma  of,  986 

pin  iit  a-  of,  986 

sarooma    of,  991 

syphilis  of,  986 

venerea]  aflectione  of,  986 

wan-  of.  987 

\  ui\ in-,  aphthous,  987 
gonococcal,  986 

leuooplakic,  988 

phagedenic,  986 

pneumococcal,  986 

simple,  986 

staphylococcal,  986 

streptococcal,  986 

tuberculous,  987 

Wandering  rash,  177 

WasBermann's  reaction  (see  Fixation-of- 

oomplement) 
Webbed  penis,  965 
Weir-Mitchell     treatment     in     movable 

kidney.  795 
Wertheim's  operation,  1024 
Wheelhouse's  operation,  896 
Whitehead  s  operation  for  lingual  carci- 
noma. 219 

for  piles,  680 

for   rectal  and   anal   stricture, 

706 

ulceration.  703 

"  Wooden  tongue,"  209 

X-ray  examination  in  foreign  bodies  in 
oesophagus,  269,  270 

in  fused  kidneys,  790 

in  hour-glass  stomach,  323 

in  hydronephrosis,  817 

in      malignant      tumours      of 

kidney,  822 

■  in  oesophageal  carcinoma,  288 

in  renal  calculus.  835 

in  ureteral  calculus.  844 

in  vesical  calculus,  875 

of  intestines,  439 

■  of  oesophagus.  257 

of  stomach,  308 

of  ureter,  840 

X-rays    in    carcinoma   of   breast,    after- 
treatment,  93 

inoperable,  94 

salivary,  248 

in  chronic  mastitis,  26 

Yeast  fungi  in  gastric  disease,  311 

Zinc  cataphoresis  in  rectal  ulceration. 

702 
in   salivary   carcinoma,   248 


Printed  by 

Cassell  and  Compasy,  Limited,  La  Belle  Salvage, 

London,  E.C. 

10.1113 


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System  of   surgery 


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